Facility Evaluation Report

On 09/13/21 at 3:15PM, LIcensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced case management visit as a result of receiving 5 self reported incidents dated 09/02/21 submitted to CCLD regarding clients' lack of supervision at the facility. LPA explained the purpose of the visit with administrator (ADM). Routine COVID-19 symptom checks was done to LPA by staff wearing face mask at the front entrance. LPA observed 5 clients sitting comfortably in their own individual wheelchairs and 4 staff wearing face masks during visit. Two clients were watching TV in the living room while the other 3 clients were resting inside their bedrooms.

ADM stated to LPA that he received a progress report dated 09/01/21 from staff (S1) who stated that one morning, LVN (S2) and another CNA (S3) on AM shift duty left the facility before 8AM to buy chips and dip at a local store, leaving 2 other CNA's (S1 and S5) providing care to 5 clients for over 20 minutes. ADM stated 1 client (R1) require 24 hour one-on-one care while another client (R3) require 10 hours one-on-one care.

LPA interviewed S5 who confirmed that both S2 and S3 were not at the facility between 7:30AM and 8AM when he needed to administer R1's scheduled AM medications. S5 witnessed S2 and S3 come back to the facilty with chips and dip past 8AM. S5 stated this incident happened 4 or 5 months ago and could not remember the exact date. ADM stated he only knew about this incident when he received the progress report from S1 on 09/01/21.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099 D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties .

Exit interview conducted. Appeal Rights and a copy of this report provided.