Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to open a complaint investigation. During visit, a case management deficiencies visit was conducted due violations observed. LPA met with Licensee, Corey Ebadat.

During visit, LPA was sitting at the dining room table and observed resident (R1) open the centrally stored medication cabinet, grab a cub of pre-poured medication, and self administer the cup of medication while staff (S1) was sitting in the kitchen eating a meal. S1 stated to have prepared R1's medication this morning but R1 was not able to take the medication earlier this morning due to a medical appointment.

LPA observed the medication cabinet was unlocked. LPA spoke with staff (S2) who states the medication cabinet should always be locked and they unlock the cabinet if a resident needs medication.

At 11:15am, LPA entered 3 resident bedrooms with staff (S2). LPA observed 3 resident (R2 - R4) beds contained full length bed rails. Based on interview, the staff utilize the full-length bed rails during the night for safety reasons. LPA reviewed R2 - R4's files and did not observe a physician's order and any information in their IPP or appraisal/needs regarding the use of full-length bed rails. Licensee was advised.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D.

This report was reviewed with Licensee, Corey Ebadat and a copy of the report and appeal rights were provided.