Facility Evaluation Report

On 3/7/2024 Licensing Program Analysts (LPAs) B. Miranda and S. Doucette arrived to the facility unannounced to conduct a case management visit. LPAs introduced themselves and explained the reason for the visit. LPAs were allowed entry into the facility and Administrator (AD) Hasmik Nshanyan was contacted via phone. AD stated they were on their way and would arrive in about 45 minutes.

LPAs observed facility to be clean, clutter & odor free. LPAs requested resident files to review while waiting for AD to arrive. Staff told LPAs to wait for AD. Due to staff not complying with LPAs requests to review resident records deficiency was cited.

LPAs observed R1 & R2 in room 1. R1 has full bed rails on bed. LPAs reviewed R1's chart which did not indicate resident was on hospice and did not have a doctor's order on file for full bed rails. Due to facility not having proper documentation for full bed rails deficiency was cited.

Resident records were reviewed. During the review R3's centrally stored log was not current and up to date. After reviewing R3's Oxycodone medication and AD conducting a medication count the start date did not match the medication count deficiencies were cited

All deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC 809D .

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Hasmik Nshanyan.