Facility Evaluation Report

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 07/30/2024. The LPA met with Administrator, Amber Winterstein and informed them of the reason for the visit. Entrance interview.

Today the LPA conducted two (2) staff interviews, a medication audit and finished the record review initiated on 7/30/2024.

Record Review: The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 06/18/2024). T he LPA also reviewed Personnel Training. The following was observed: S1 is missing six (6) required annual training hours in dementia, and two hours and thirty minutes (2.5) required annual training hours in Postural supports, restricted health conditions, and hospice. S2 is missing 3.25 hours in dementia, and 2.50 hours in Postural supports, and restricted health conditions. S3 is missing 2 hours in Postural supports, restricted health conditions. S4 is missing 2 hours in policies and procedures regarding medications, 2 hours in postural supports and restricted health conditions.

Medications: At 1:25 p.m. a medication review was initiated for two out of five residents and the following was observed. The medications were stored in a Medication room, which is locked and inaccessible to the residents. During Resident #1 (R#1's) audit, the LPA observed two (2) PRN medications not documented in the Facility Centrally Stored Medication and Destruction Record (CSMDR). Upon observation, MedTech recorded the medications on the CSMDR. The LPA also observed three (3) PRN medications with a start date, however all 3 medications had not been started, and one (1) PRN medication had the wrong start date noted on the CSMDR.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.