Facility Evaluation Report

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - other visit. LPA met with Administrator, Joseph Lansana.

The purpose of the visit is to follow-up on a report the Department received from a semi-annual review from the Department of Developmental Services (DDS).

On 05/22/2024, the facility had a semi-annual review with DDS. During the review, it was observed that resident (R1) was being served lunch and staff did not follow the specific feeding instructions, per R1's physician's order.

During visit, LPA interviewed 2 staff members. Based on interview, the staff stated that R1's food mixture was stewing for a longer period, which resulted in the consistency being pudding-thick rather than honey-thick. Staff (S2) admitted that the incident did occur but knew that R1 should have been fed a honey-liquid consistency mixture. S2 states he/she was provided training after the incident. Going forward, S2 states he/she is more careful about ensuring R1 is being fed the right liquid consistency.

LPA obtained R1's physician's report, physician's order, and training documentation. The review of records show that staff were provided training on R1's liquid consistency mixture and feeding and liquid presentation. Staff were also provided a training video regarding liquid consistency mixtures.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Joseph Lansana and a copy of the report and appeal rights were provided.