Facility Evaluation Report

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Case Management visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Teresita Duclayan. Licensee Myrna Arcelao later joined the visit.

When LPA arrived at the facility there was a couch blocking the front door preventing LPA from entering. Per interview with caregiver the couch was placed in front of the door to prevent Resident #1 (R1) from eloping. [See LIC811 Confidential Name List for a description of select person identifiers used in this report.] Caregiver reported they cannot keep an eye on R1 when tending to other residents because they were the only staff at the facility at that time. Caregiver immediately moved the couch to allow full access of the front door.

LPA observed R1 exit the facility in an elopement attempt while staff was in the kitchen. LPA followed R1 out and was able to keep R1 from going into the street. LPA stayed with R1 for some time, who refused to go back inside the facility. Caregiver came outside to stay with R1 at which point LPA went inside the facility and there were no other staff inside the facility to provide supervision to the other residents.

Additionally, LPA observed R1 to be restrained by a postural support. R1 was unable remove the restraint independently. A review of R1's records revealed that there is not a physician's order for postural support. Further, a review of all resident records revealed none of the residents had signed Personal Rights in their records.

Four deficiencies were observed and cited during todays visit per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages), including a Civil Penalty totaling $500 (refer to LIC 421IM). A plan of correction was jointly developed with Licensee Myrna Arcelao. Due to three Type A deficiencies being cited, LPA informed Licensee that an office meeting will be scheduled at a later date. An exit interview was conducted with Licensee, to whom a copy of this report, the LIC 809-D, LIC 421IM, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.