Facility Evaluation Report

Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year Continuation inspection at the facility today. This is a continuation from the 11/03/2021 Required - 1 Year inspection. Today, the LPA met with Administrator Julie Anos and explained the reason for the inspection.

At 1:00 PM the LPA began record review of ten resident files and five staff files. File review of 10 resident files revealed one (1) resident, Resident #1 (R1), out of ten (10) files reviewed was missing TB results. Resident file review also revealed, one resident, Resident #2 (R2) out of ten (10) files reviewed were missing the second page of their medical assessment. Resident files reviewed were otherwise complete. Staff file review revealed, one staff, Staff #1 (S1) out of five staff were missing a physical with TB results. Staff files reviewed were otherwise complete.

At 2:46 PM, the LPA and the Administrator reviewed medications which are centrally stored in a locked office upstairs. The LPA observed the centrally stored medications records for all residents to be incomplete as the start date of the use of the residents prescription medications is not documented in the centrally stored medication records. Therefore, the LPA was unable to determine if medications are being self-administered as prescribed. First aid supplies were observed to be complete.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview and report reviewed with the Administrator. A copy of the report will be emailed.