Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived to the facility to conduct a case management visit regarding three incident reports the Department received. LPA met with Caregiver and explained the purpose of the visit. Administrator then arrived to the facility shortly afterwards.

The first incident report was regarding R1 who left the facility unsupervised at approximately 5:30AM and was found an hour later by local law enforcement. The date of occurrence was 06-15-2024, which the Department was not notified until 10-01-2024. Note that facility was cited on 12-14-2023 and 9-19-2024 for failing to met reporting requirements.

The second incident report occurred on 09-21-2024 regarding R1 again who left the facility unsupervised at approximately 2:20pm and was found by local law enforcement at approximately 3:40pm. Base on file review of R1's LIC 602A Physician's Report for Residential Care Facilities for the Elderly, it revealed R1 cannot leave the facility unassisted.

The third incident report occurred on 09-25-2024 regarding R2 was transported to the emergency room as R2 was out of three medications, which R2 returned to the facility with new prescriptions orders. Based on interview conducted with Administrator revealed the empty bottles were placed to the side as a reminder for refills but was left forgotten. File review of R2's Centrally Stored Medication and Destruction Record revealed Gabapentin was refilled 7-22-2024, a month worth supply, and then the next refill was on 9-26-2024. LPA observed medication for 8-22-2024 to 9-25-2024 to be missing.

As a result, please see LIC 809-D for the deficiencies observed today. Additionally, $250 civil penalty assessed as reporting requirement violation was recently cited within a 12 month period. Exit interview and a copy of report and appeal rights provided.