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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200977
Report Date: 10/23/2024
Date Signed: 10/23/2024 01:07:36 PM

Document Has Been Signed on 10/23/2024 01:07 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:WE CARE ELDERLY CAREFACILITY NUMBER:
079200977
ADMINISTRATOR/
DIRECTOR:		WHITE, BRITTANY DFACILITY TYPE:
740
ADDRESS:4155 BELL AVETELEPHONE:
(510) 375-4460
CITY:RICHMONDSTATE: CAZIP CODE:
94804
CAPACITY: 8CENSUS: 4DATE:
10/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Lurinza Bean, Licensee
Brittany White, Administrator		TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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
On 10/23/24 around 9:45 AM, L. Holmes Licensing Program Analyst (LPA) arrived unannounced to conduct a case management regarding an Unusual/Incident Reports (UIR) and Death Report (DR) for Resident (R1) LPA met with Lurinza Bean, Licensee (S2) and explained the purpose of the visit; ADM Brittany White arrived shorlty after.

On 10/01/24 ADM reported the following, “On 9/26/2024 R1 was having a virtual MD appointment, and We Care is requesting the primary care MD approve a request for a hospice evaluation due to recent decline. During appointment, the MD verbally instructed that Licensee, S2 to send R1 to ER for evaluation due to noted change in condition. 911 was alerted. Upon arrival to community, they successfully transported pt to ER for further medical evaluation. Pt conservator informed. Permission given for Hospice Evaluation Continue communicating to St. Mary's Hospital that pt needs a hospice evaluation.”

During the visit on 10/09/24, LPA reviewed the file for R1 including but not limited to R1's After visit summary for 09/2024 & 07/2024, and Identification and Emergency Information. On 10/14/24, ADM sent R1’s Physician’s Report (LIC 602) and DR for death dated 10/13/24. After careful review of R1’s medical history with LPM Y. Flores-Larios, LPA returned to review R1’s Medication Administration Records (MAR) and Centrally Stored Medication and Destruction Record )LIC 622) for accuracy. ADM stated that she will provide additional faxes and emails to support the change in R1's condition.

-At around 10:59 AM, LPA found that the records were inaccurate for a sample of seven (7) out of eleven (11) medications on the MAR and LIC 622 when compared to the after visit summary medication list on 06/04/2024.


Deficiencies are cited on the attached LIC 809D. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided to Licensee, Brittany White, Administrator

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/23/2024 01:07 PM - It Cannot Be Edited


Created By: Lisha Holmes On 10/23/2024 at 12:05 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: WE CARE ELDERLY CARE
FACILITY NUMBER: 079200977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2024
Section Cited
CCR
87475(e)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription...shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication...
1
2
3
4
5
6
7
Licensee and ADM to have physicians consolidate/update medication lists for all residents by 10/30/24. All residents' medication shall be available.
8
9
10
11
12
13
14
-This requirement is not met as evidenced by:

Based on interviews and records reviewed, the licensee did not comply with the section above by not having R1’s medication to be administered available which posed an immediate safety risk to persons in care.
8
9
10
11
12
13
14
Document refusals date and time, follow physician’s orders, and perform staff training for all personnel that administer medication by 10/25/24; submit proof of training with names of attendees to CCLD on or before 10/25/24.
Type A
10/23/2024
Section Cited
CCR87506(b)()14

1
2
3
4
5
6
7
87506 Resident Records (b) Each resident’s record shall contain at least the following information: (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services.-This requirement is not met as evidenced by:

1
2
3
4
5
6
7
Licensee and ADM to audit all residents LIC 622s, follow physician’s orders, and perform staff training for all personnel that administer medication by 10/25/24; submit proof of training with names of attendees to CCLD on or before 10/25/24.
8
9
10
11
12
13
14
Based on interviews and records reviewed, the licensee did not comply with the section above by not having all of R1’s medications recorded on the LIC 622 which posed an immediate safety risk to persons 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.
SUPERVISOR'S NAME:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Lisha Holmes
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2