Non-compliance follow-up·May 15, 2023

Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced required annual visit. Along with the annual visit, the purpose of today’s visit was to ensure the facility was maintaining substantial compliance as discussed in the Non-Compliance Conference that took place on 10/26/2022. As a result of the non-compliance conference, the licensee is placed on frequent monitoring for a period of two years. The LPA met with Executive Director Stephanie Funderburg and explained the reason for the visit. The last visit was conducted 2/6/2023. A file review of five (5) resident files was conducted from 9:45 a.m. – 11:15 a.m. Five files were reviewed for, but not limited to: admissions agreements, medical assessment, updated appraisals, consent forms. Out of the five files review, one out of five resident records (Resident #1 – R1) was missing a signed admissions/residency agreement. Technical violation issued, as parts of the residency agreement were observed in the file. Otherwise, resident records were in order. A medication review for five residents was conducted from 11:30 a.m. – 2 p.m. The following was noted: - R1 had an as-needed medication (Acetaminophen 650mg) that was administered one (1) time; however, staff did not document that R1 was assisted with this PRN medication as required per regulation. - Resident #2 (R2) had an as-needed medication (Anti-Diarrhea 2mg) that was administered two (2) times since 3/11/2023; however, staff did not document that R2 was assisted with this PRN medication as required per regulation. - Resident #3 (R3) had an as-needed medication (Acetaminophen 650mg (2 tabs – 325mg) that was administered one (1) time since 3/23/2023; however, staff did not document that R3 was assisted with this PRN medication as required per regulation. The following deficiencies were observed (See LIC 809-D.) and cited from the CA Code of Regulations, Title 22.Exit interview conducted. A copy of the report and appeal rights were provided.