<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045000644
Report Date: 10/04/2022
Date Signed: 10/04/2022 05:41:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2022 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20220222153457
FACILITY NAME:PRESTIGE ASSISTED LIVING AT CHICOFACILITY NUMBER:
045000644
ADMINISTRATOR:MICELI, JOSEPHFACILITY TYPE:
740
ADDRESS:1351 E. LASSEN AVENUETELEPHONE:
(530) 899-0814
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:79CENSUS: 57DATE:
10/04/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:ED Eric PerryTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff bullied residents
Staff did not ensure that resident's toileting needs were met
Staff mismanaged resident medications
Staff did not keep the facility free from trash
Residents laundry not done
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/4/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced complaint investigation visit regarding the above allegations and met with Current Executive Director Eric Perry. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95


6/26/2022 at 11:58 AM, the Department conducted a site visit and toured the facility including the facility Expressions Memory Care unit with Rachel Hernandez, Residential Care Coordinator (RCC) The following are observations were made during the tour:

Cont'd on 9099-C
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 9
Control Number 25-AS-20220222153457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: PRESTIGE ASSISTED LIVING AT CHICO
FACILITY NUMBER: 045000644
VISIT DATE: 10/04/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
R1’s room 11:58AM
Observed Preparation H and Neosporin in restroom medicine cabinet, toilet bowl was unsanitary and dark brown in color, shower floor was full of debris, drain partially blocked with debris. Regarding R1’s care. Per R1’s Physicians Report (LIC 602) provided by facility administrator, dated 06/15/2022, R1 is diagnosed with dementia and is marked yes at risk if allowed direct access to personal grooming/hygiene. LIC 602 indicated, R1 is unable to administer or store medications, incontinent, and full assist with ADL.

R2’s room 1159AMDocument Link Icon
Laminate floor heavily soiled with dried liquid, observed resident’s clothes that resident is wearing to be heavily soiled. In room AC unit filter caked with dust. Bathroom smelt of urine and feces. Feces were in unlined trash can in bathroom. Toilet seat was covered in debris, inside of toilet bowl was pink and brown in color, fan vent was caked in dust. Regarding R2’s care. The Department observed the resident to be in soiled cloths. Staff said R2 should be showered 2 times per week however R2 is not. R2’s assessment states R2 only requires verbal prompting to bathe however he refuses and will go 2-3 weeks without bathing. The Department requested and was provided the resident’s Physicians Report (LIC 602) dated 9/23/2020 by Facility Administrator July 2022. LIC 602 indicates R2 has a diagnosis of dementia. LIC 602 indicates R2 does not have a bladder or bowel impairment however staff interviews indicate that R2 often soils themselves. It has been longer than a year since LIC 602 was last updated by the doctor which is a violation of regulation.

R3’s room 12:02 PM
Bathroom smelt of urine and feces, soiled briefs were in bathroom trash can, toilet bowl heavily soiled and brown in color. Regarding R3’s care. R3 LIC 602 dated 1/10/2022. Resident diagnosed with dementia. Cannot bathe or groom self.

Memory Care Kitchenette 12:05 PM
Observed in the refrigerator, plates of food not labeled with name or date, freezer container of unlabeled food without a lid, kitchen island drawer broken lock contained sharp kitchen tools such as wine opener meat thermometer, vegetable peeler accessible to residents in care.

Community bathroom on memory care side 12:07 PM
Flooring is white in color however at the base of the toilet is red and dark brown in color. Toilet bowl has brown ring.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 25-AS-20220222153457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: PRESTIGE ASSISTED LIVING AT CHICO
FACILITY NUMBER: 045000644
VISIT DATE: 10/04/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Activities room in memory care 12:08 PM
Observed resident 4 (R4) unsupervised at desk in community area with hand sanitizer and Clorox wipes within arm’s reach and accessible to R4 and other residents in memory care a violation of regulation.

R4’s room 12:10 PM
Room unlocked and accessible to memory care residents, Debris on carpet, supplemental protein drinks, Purell hand sanitizer wipes, toilet bowl covered in feces, shower floor heavily stained, 3 bottles of Purell in medicine cabinet. Regarding R4’s care. R4’s Physicians Report (LIC 602) dated 05/16/2022 R4 is diagnosed with dementia, unable to care for own toileting needs/bathe self/dress or groom self and utilizes a wheelchair. R4 is unable to administer own PRN or store own medications

Memory Care outside Courtyard at 12:17 PM
All doors from Memory care to the courtyard were propped open due to broken AC. Near a wooden planter observed gardening potting mix and hand shovel.

At 12:29 PM, Assisted Living Side of building toured with RCC and the following are observations made:

R5’s room 12:29 PM
Clorox disinfecting wipes in cabinet above fridge, in freezer ice tray with mold, recliner with soiled white towel with brown debris, bathroom counter glad air freshener spray containing caution labeling, bathroom sink was covered in brown debris, toilet had feces smeared on front of bowl and on toilet seat. Base of toilet was dark brown and red in color. Floor In front of resident recliner was soiled with spit and tobacco debris. Regarding R5’s care. The Department reviewed R’5s LIC 602 from 06/05/2019 and assessment from 6/19/2019 that was provided by the facility. LIC 602 and assessment have not been updated even though R5 has been sent out to the hospital more than 10 times and hospitalized at least twice in 2022. Due to the change in condition, the LIC 602 and assessments should be updated to ensure R5s needs are being met and is still a fit for assisted living.

R6’s room 12:31 PM
Bathroom toilet bowl and assistive device over toilet covered in debris. Behind the toilet on the floor was a toothbrush, electronic razor broken into pieces, bathroom trash can full of soiled gloves, purple/white scissors on desk. Regarding R6’s care. The Department reviewed R6’s LIC 602 dated 12/16/2019. Resident is full assist with ADLs, cannot transfer independently to and from bed. Staff interviewed stated R6 utilized a wheelchair and is a 2 person assist.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 25-AS-20220222153457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: PRESTIGE ASSISTED LIVING AT CHICO
FACILITY NUMBER: 045000644
VISIT DATE: 10/04/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
R7’s room 12:32 PM
White carpet heavily soiled with dark brown stains, scissors on tray table over the resident, Lysol disinfectant spray on counter in bathroom. The Department’s review of R7’s LIC 602 dated 2/22/2022 R7 is diagnosed MCI, needs assist with bathing, dressing, toileting and medications, cannot independently transfer to and from bed. The administrator identified resident to be 2-person assist.

Kitchen at 12:41 PM
Rotting red onions, rotting honeydew melon cut and not labeled, food outside of original container not labeled or dated, Rotting celery

Administrator identified the following residents as two person assist:

Assisted Living Side: R8, R7, R8
Memory Care: R9

During interviews with Staff. Staff identified the following residents to be 2 person transfers not indicated by administrator:

Assisted Living Side: R10 and R6

The Department requested and was provided by the facility the schedule dated 6/12-6/25/2022 NOC shift (10PM-6AM)

NPH (contracted direct care staff through Nurses and Professional Healthcare)
MT (Med tech)
MC (Memory Care Side)
AL (Assisted Living Side)
PCA (Personal Care Attendant/caregiver)


Cont'd on LIC 9099-C
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 25-AS-20220222153457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: PRESTIGE ASSISTED LIVING AT CHICO
FACILITY NUMBER: 045000644
VISIT DATE: 10/04/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The following dates per the schedule there were only two staff scheduled for the entire building regardless of the fact that the Memory Care Unit is separate from the Assisted Living Side of the building meaning that if 2 staff are attending to a resident who require 2 staff to transfer on one side of the building, there is no supervision on the other side of the building.

Mon 6/13/2022 scheduled 1 NPH MT, 1 MC PCA
Tue 6/14/2022 scheduled 1AL PCA, 1 MC PCA
Thu 6/16/2022 scheduled 1 MT, 1 MC PCA
Fri 6/17/2022 Scheduled 1 MC PCA
Sat 6/18/2022 Scheduled 1 MT, 1 MC PCA
Mon 6/20/2022 Scheduled 1 MT, 1 MC PCA
Tues 6/21/2022 Scheduled 1 MT, 1 MC PCA
Wed 6/22/2022 Scheduled 1 MT, 1MC PCA
Thu 6/23/2022 Scheduled 1 MT, 1 MC PCA
Sat 6/25/2022 Scheduled 1 MT, 1 MC PCA

The Department requested a breakdown of the census provided by the administrator. Memory care Census 14 residents
Assisted Living side 1st floor census 23
2nd floor census 23
Total of 60 residents

The Department learned that on several occasions the Administrator worked NOC shift due to the lack of staff. Administrator provided the following dates and positions worked during time frame listed above.

Thu 6/16/2022 AL PCA
Fri 6/17/2022 MT
Sat 6/18/2022 AL PCA


Cont'd on LIC 9099-C
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 25-AS-20220222153457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: PRESTIGE ASSISTED LIVING AT CHICO
FACILITY NUMBER: 045000644
VISIT DATE: 10/04/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
All staff interviewed indicated that trash is not taken out nor is laundry done due to prioritizing resident care. Direct care staff indicated it is one of their many responsibilities to clean, take out trash and do laundry. Direct care staff interviewed said since the facility removed the “shower shift” not only is the cleaning not being done, trash not being taken out, or laundry not being done, residents are not being showered as scheduled. Staff interviewed all stated that R8 has been left soiled in feces due to the need for two staff to transfer and there not being enough staff to provide R8 with that type of care. Staff interviewed stated that often times residents who are able to utilize the toilet but require staff assistance are not toileted often enough and placed in depends in the event they become incontinent. Staff stated this is due to the lack of staffing and having to leave one resident for another. Observations reported by staff is that the acuity of residents has increased and on average its 1 caregiver to 20 residents during AM and PM shift. Staff interviewed expressed the difficulties with getting residents up for the day and to the dining room on time. Staff reported they are also responsible for resident meal orders and serving.

Med techs interviewed stated they are responsible for med passes on both floors on AL side and at times to include memory care med passes due to lack of staffing. All med techs interviewed stated they either have been responsible for med errors themselves or caught med errors made by peers. The following are med errors identified by staff:

MAR for R11
On June 1-4th, 2022 did not receive his Finasteride Tablet 5 MG. MAR coded MC-Med not received

MAR for R9
On June 4-8th, 2022 did not receive her amlodipine Besylate Tablet 5 MG. MAR coded MC-Med not received

On June 15th, 18th and 24th, 2022 did not receive Furosemide Tablet 20 MG. MAR coded MC -med not received. On June 27 and 30, 2022, MAR is blank and does not indicate medication was given and there is no reasoning listed.

Based on the Department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/22/2022 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20220222153457

FACILITY NAME:PRESTIGE ASSISTED LIVING AT CHICOFACILITY NUMBER:
045000644
ADMINISTRATOR:MICELI, JOSEPHFACILITY TYPE:
740
ADDRESS:1351 E. LASSEN AVENUETELEPHONE:
(530) 899-0814
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:79CENSUS: 57DATE:
10/04/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:ED Eric PerryTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of care and supervision resulting in injury to residents
Staff did not ensure that residents were adequately fed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The Department received conflicting statements regarding the injuries caused by staff to residents as well as whether or not residents are adequately fed.

Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 25-AS-20220222153457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PRESTIGE ASSISTED LIVING AT CHICO
FACILITY NUMBER: 045000644
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2022
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee said since weakness was identified, Licensee has hired 2 house keeping staff and a maintenance person
8
9
10
11
12
13
14
Based upon observation and interview the Licensee failed to maintain Memory Care in a safe and sanitary manner.

This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.
8
9
10
11
12
13
14
Type A
10/05/2022
Section Cited
CCR
87468.2(a)(8)
1
2
3
4
5
6
7
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1...Shall-- (8) be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to do an inservice training on personal rights at next all staff meeting. Licensee will send LPA date for training by COB 10/5/2022.
8
9
10
11
12
13
14
Based upon document review and interview the Licensee failed to ensure the personal rights of all residents in care.

This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 25-AS-20220222153457
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PRESTIGE ASSISTED LIVING AT CHICO
FACILITY NUMBER: 045000644
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2022
Section Cited
CCR
87411
1
2
3
4
5
6
7
87411 Personnel Requirements-(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required... Additional staff shall be employed... to perform .., house cleaning, laundering, and maintenance...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided,...such additional staff for the provision of adequate services.
1
2
3
4
5
6
7
Licensee agrees to provide CCLD with a written contengency plan to cover NOC shift in the event there is more than one call off. Plan will be provided by COB on 10/5/2022.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to toilet residents, assist with laundry and provide immediate assistance to residents who are two person assist due insufficient staffing.This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.
8
9
10
11
12
13
14
Type A
10/05/2022
Section Cited
CCR
87465
1
2
3
4
5
6
7
87465(a)(5) Incidental Medical and Dental Care. A plan for incidental medical and dental care shall be developed by each facility...by compliance with the following: The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to have House Services Director shadow each individual med tech to ensure policy and procedure is followed. Licensee agrees to have plan developed and sent to CCLD by COB on 10/5/2022
8
9
10
11
12
13
14
Based upon document review and interview the Licensee failed provide medication as prescribed to residents in care.

This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 9