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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200834
Report Date: 10/04/2023
Date Signed: 10/04/2023 03:22:49 PM


Document Has Been Signed on 10/04/2023 03:22 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:TERRACE VIEW ASSISTED LIVINGFACILITY NUMBER:
079200834
ADMINISTRATOR:MICHAELSON, MANJULAFACILITY TYPE:
740
ADDRESS:2828 TERRACE VIEW AVETELEPHONE:
(925) 354-0403
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:3CENSUS: 2DATE:
10/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Manjula Michaelson, AdministratorTIME COMPLETED:
05:30 PM
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On 10/04/23 at 2:15PM, Licensing Program Analyst (LPA) conducted an unannounced case management visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM. LPA observed only two residents (R1, R2) are living at the facility.

During visit, the department obtained the following documents from administrator - staff roster, residents' roster, admission agreements, physicians reports, ID/Emergency information, hospital discharge reports, Centrally stored medication logs and Medication administration records.

Review of R1 & R2's centrally stored medication logs and medication administration records dated 04/2023 until 10/2023 show staff assists both residents with taking prescribed and over the counter medications in accordance with physicians' instructions. LPA observed both residents are diagnosed with dementia. ADM stated she administers each resident's medication as prescribed by their primary care physicians. ADM stated she did not replace residents' prescribed medications with herbal supplements nor stop administering their prescribed & PRN medications. Based on records review, interviews conducted, and observations made, the allegation that staff stopped administering prescribed medications to residents and replaced them with herbal supplements is unsubstantiated.

No deficiency cited during visit. Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
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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