Facility Evaluation Report

At 4:20 pm on this day, August 11, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced, and met with Crizaldo Robles, staff, and informed the reason for visit. LPA sent message to Joseph Crisol, administrator. Administrator can not come to the facility, ad authorized Crizaldo Robles to sign and receive this report.

LPA reviewed 5 residents records and interviewed 3 residents. P&I records reviewed. Medications were checked and compared with doctor's orders and records.

LPA received copies of the following updated documents:

1. LIC308 Designation of Facility Responsibility

2. LIC610D Emergency Disaster Plan (9 pages)

At 5:55 pm, LPA observed resident's (R1, R2, R3, R4 and R5) LIC622 Centrally Stored Medication and Destruction Records not complete - the expiration dates and dates medications started were blank.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.