Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection visit and used the CARE Inspection Tool. LPA Yee met with Marine Ghukasyan, Administrator. The reason for today's visit was provided.

The home is a single storey family home consisting of a living room, dining room, family room, kitchen, 4 bedrooms of which one will be used for live-in staff and as an office, 2 full bathrooms and a attached garage. The facility is fire cleared for 5 NON-AMBULATORY and 1 BEDRIDDEN residents. Bedroom #2 is the room designated for bedridden use.

On today's visit, LPA Yee reviewed 3 resident files and 4 staff files, reviewed medications and Medication Administration Record for Resident #3 and attempted to complete the infection control domain but was able to answer 32 questions only.

The following were observed on today's visit:

All three residents are receiving PRN medications but there are no completed PRN Authorization Letters on file to determine if the residents are able or unable to request their medications if needed or if staff should be contacting the physician for instructions prior to administrating the medications based on the residents' symptoms. During this visit, LPA Yee observed the Administrator dispense a pain pill to Resident #3 and it was refused by the resident. No contact was made with the physician.

MAR logs are not being documented correctly. The daily MAR log is checked off when medications are dispensed and the staff dispensing the medication is unknown. The facility also keeps a separate MAR log for PRNs and cycle medications are included with a different time and looks like duplication of medications. Medication training was provided by the Administrator but documentation was unavailable.