Facility Evaluation Report, 01/25/2024 — Dutchollow Suites I, Modesto CA

On 1/25/24 Licensing Program Analyst (LPA) Maja Jensen and Stanislaus County Ombudsman Josey Samson arrived at facility unannounced to conduct a quarterly visit. LPA Jensen met with Licensee Cecelia Candido and Co-Administrator Nikolas Adamsson and explained the purpose of today's visit.

The Licensee was informed that at any time if she wishes to use an interpreter the Department will provide an interpreter upon request. The facility currently has a census of 2. LPA Jensen requested the file for Resident 2 (R2). LPA Jensen observed an Admission agreement dated 4/13/2018 stating that the resident has a double room. LPA Jensen also observed 2 receipts billing for a private room. One receipt for April through June and one receipt for April through May of 2018. LPA Jensen asked the Licensee why there are receipts in the file billing for a private room and an admission agreement stating there R2 will occupy a double room. The Licensee stated the receipts in question were never sent and were placed in the file in error. The Licensee confirmed that the resident has always occupied a double occupancy room. LPA Jensen requested the correct receipts and was advised no other receipts were ever sent or generated. LPA Jensen observed the Needs and Service Plan for R2 to be dated April 2, 2018. The Licensee produced an additional Needs and Service Plan dated 3/23/2019 with no signatures.

LPA Jensen reviewed the Medication Administration Record (MAR) for R2, the MAR reflects that on January 11 through and including January 15, 2024, R2 did not receive a prescribed dopamine promoter. LPA Jensen was advised that the prescription medication ran out on January 10, 2024 and the facility placed 3 calls to the pharmacy for a refill but these calls were not documented. LPA Jensen reviewed the Centrally Stored Medication and Destruction Record which shows that the prescription was refilled 12/21/23 and was started on 1/7/24. There was no explanation as to why these records were in conflict.

LPA Jensen tested the water in the bathroom toward the rear of the facility and the temperature was measured at 103 degrees. Technical assistance was provided.