Facility Evaluation Report

Licensing Program Analyst (LPA) Teresa Camara conducted a case management - deficiencies visit to the facility. LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Liz Aced-Arnett. LPA and QAS initially met with lead staff 1 (S1) as the administrator was out of town. Administrator DiDi Daniel arrived at the facility at 1:30 p.m. LPA explained the reason for the visit.

During the course of investigating two complaints (29-AS-20230412125937 and 29-AS-20230816091820) other deficiencies were observed.

At 11:50 a.m. LPA and QAS reviewed medications and records. It was found that Client 1 (C1) missed/refused their two 4:00 p.m. medications. However, the administrator failed to report this missed medication to TCRC or Community Care Licensing (CCL).

In addition, there was a note written by staff to discontinue one of C1's medications but there was no physician's order found to discontinue the medication. There was another staff note stating the same medication was having the dosage changed, however there was no physician's order stating such. C1 has not been taking this medication as prescribed for more than a month. During LPA's visit the administrator reached out to C1's physician and found the dosage had been changed but the prescription had not been called in to the pharmacy, nor did the physician send a copy of the order to the facility. The administrator will follow up to ensure the order and medication are received and C1 gets back on the medication immediately.

Lastly, LPA found that the Centrally Stored Medication and Destruction Record (CSMDR) for all clients were incomplete.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview was conducted. Report and appeal rights were reviewed and emailed to the Administrator.