Facility Evaluation Report

On 3/5/2024, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced to conduct a case management visit. LPA initially met with a staff on duty and explained the purpose of the visit. The facility administrators, Aida Gatchalian and Ma Magnolia Tolon, were notified of this visit and arrived shortly after.

Present during this visit are 3 residents in care with 2 staff on duty.

The purpose of this visit was to follow up on an exception request regarding Resident 1(R1).

LPA reviewed R1's facility file including but not limited to Pre-Appraisal, Needs and Services Plan and Physician's Report. It was learned through record review and interviews that the resident has been using indwelling Foley catheter continuously since November 2023 without an exception request. The needs and services plan dated on 3/20/2023 states that R1 is on and off on the use of Foley catheter. In addition, a review of the resident's home health notes indicates that R1 has been seen for routine catheter changes since 11/1/23 and R1 gets routine catheter changes every 4 weeks.

Based on interviews conducted, it was learned that the resident does not clean their catheter and needs staff assistance at this time. Aida and Ma Magnolia stated that they were not aware that an exception request was needed to be sent to the department for the use of catheter.

Based on the information gathered during the course of this visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, the following deficiencies are being cited today in violation of California Code of Regulations.

An exit interview was conducted with Aida and Ma Magnolia and a copy of this report and appeals rights were provided to the facility at the end of this visit.