Routine inspection (multi-day)·January 16, 2024

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 07/11/2023. The LPA was greeted by Business Office Manager Hannah Robertson and informed them of the reason for the visit. Administrator Lance Shenk arrived during the visit. Today the LPA conducted a medication audit and finished the record review initiated on 7/11/2023. Record Review: The LPA observed documentation of Disaster prevention and last fire drill (conducted on 12/12/2023). Medications: At 2:30 p.m. a medication review was initiated for two out of five residents and the following was observed. The medications were stored in Med carts, which are locked and inaccessible to the residents. During Resident #1 (R#1's) audit, the LPA observed the expiration date for fifteen (15) medications not properly documented as they did do not match the Facility Centrally Stored Medication and Destruction Record (CSMDR). During R#2’s audit, there were two medications that were not documented on the centrally stored log. Staff stated the CSMDR for those medications were stored in a different location due to the date they were filled. The LPA also observed the expiration date for nine (9) medications of R2 not properly documented as they did not match the CSMDR. R2’s date started for Vitamin D2 1.25mg and Lorazepam 1mg were not properly documented, as R2 has not started the medication and a start date was documented. Staff documented the correct expiration dates and corrected the start dates upon observation. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.