Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a continuation of the annual inspection from 5/22/2024 and met with Director of Health Services, Adriana De La O and Administrator Ryan Golze.

During today's visit, LPA Rai continued to review 10 resident files and 8 staff files.

LPA Rai reviewed at random resident's Centrally Stored Medication Log and centrally stored medications in the Medroom. LPA Rai reviewed Resident #11's medication #1 the number of tablets in the bottle did not match the Central Stored Medication Record. Medication #1 should have 149 tablets in the bottle, LPA and Director of Health Services, Adriana De La O observed 155 tablets, which meant there were 6 extra tablets in the bottle. LPA Rai re-counted the medication with Staff S1 as well and the medication count in the bottle was 155.

87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation observed in Medroom are not competent to provide the services necessary to meet the resident's needs.

Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Director of Health Services, Adriana De La O and Administrator Ryan Golze. A copy of the report was provided. Appeal Rights were provided.