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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200191
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:24:27 PM

Document Has Been Signed on 10/16/2024 02:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:CEDAR HOME AT NILES GROVEFACILITY NUMBER:
019200191
ADMINISTRATOR/
DIRECTOR:		TRAN, MONIQUE NFACILITY TYPE:
735
ADDRESS:35525 NILES BLVD.TELEPHONE:
(510) 818-0716
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 6CENSUS: 6DATE:
10/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Monique Tran, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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On 10/16/2024, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen conducted an unannounced case management visit regarding an incident report that was reported to CCLD on 10/07/2024. LPAs met with Administrator, Monique Tran, and explained the purpose of the visit.

The incident occurred on 10/06/2024 when C1 was given medication in error. LPAs and Administrator discussed that C1 was given a discontinued medication from October 1,2024 to October 6, 2024. Staff knew that the medication was discontinued from the doctor's notes and the Medication Administration Record (MAR), but still continued to give the medication out to C1. After this incident occurred, Administrator had Medication In-Service Training.

Moving forward, Administrator implemented that medications will be passed out with a two person assist. One staff will assist with the medications, and the second staff will ensure that the MAR is accurate and that the medication was given out to the resident.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 02:24 PM - It Cannot Be Edited


Created By: Patricia Manalo On 10/16/2024 at 02:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CEDAR HOME AT NILES GROVE
FACILITY NUMBER: 019200191

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2024
Section Cited
CCR
80075(b)(5)(B)

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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
(5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met:
(B)Once ordered by the physician the medication is given according to the physician's directions.
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Administrator agreed to provide training to staff on medication administration and submit certificates or completion to CCLD by POC date.
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Based on record review and interview the Licensee did not comply with the section cited above in administering medication as prescribed, which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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