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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206770
Report Date: 01/17/2023
Date Signed: 01/17/2023 02:27:45 PM


Document Has Been Signed on 01/17/2023 02:27 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:POINTE AT SUMMIT HILLS, THEFACILITY NUMBER:
157206770
ADMINISTRATOR:BENNY FARILLASFACILITY TYPE:
740
ADDRESS:4501 UPLAND POINT DRIVETELEPHONE:
(661) 343-3244
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93306
CAPACITY:102CENSUS: 53DATE:
01/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Sheree Addison, Administrator
Gracie Ramirez, Assistant Administrator		TIME COMPLETED:
02:50 PM
NARRATIVE
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On 1/17/23 at 11:20 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct a case management - incident inspection. LPA explained reason for inspection at reception desk and met with Administrator (ADM) Sheree Addison and Assistant Administrator (ADM2) Gracie Ramirez.

CCL received an incident report from the facility for an incident that occurred on 12/12/22 with R1. Report indicated R1 missed a dose of Med1 on 12/12/22 at 1400. Staff (S2) contacted hospice nurse and pharmacy regarding delivery of medication. Per pharmacy, it was too soon to refill. On 12/13/22, S1 contacted pharmacy about Med1. Pharmacy stated Med1 would be delivered by 1600 on 12/13/22. Liquid Med1 was delivered on 12/13/22 instead of tablets. R1's family purchased Med1 tablets over the counter and brought it to the facility.

LPA conducted interviews and reviewed records. LPA found that on 12/12/22, S2 reported R1 missed the 2pm dose due to Med1 being out. Med1 is to be given three times per day. S2 advised S2 called the pharmacy and was told the refill was two days early. S2 notified hospice and hospice said they would see what they could do. The following day, S2 arrived to work to find a liquid form of Med1 received by the pharmacy instead of tablets. S2 admitted the liquid form of Med1 was not given as staff only administered tablets. Although the Medication Administration Record was initialed as given, S1 could not confirm if Med1 was given on 12/12/22 for the 10pm or 6AM dose on 12/13/22, as Med1 had not been filled on 12/12/22. On 12/13/22, R1's family dropped off the over-the-counter Med1 instead for administration since there was a discrepancy with the pharmacy refill. The facility did not inquire tablet refill from pharmacy after family drop off.

A deficiency is being cited based on LPA's interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and a Plan of Correction was reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left with Administrator Sheree Addison, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
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 01/17/2023 02:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: POINTE AT SUMMIT HILLS, THE
FACILITY NUMBER: 157206770

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2023
Section Cited

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical…shall be developed by each facility. The plan shall encourage routine medical…and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Administrator will submit proof of an in-service training roster of medication administration for all staff that administers medication, with training materials, to CCL by POC due date.
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LPA found that on 12/12/22, S2 reported R1 missed the 2pm dose due to Med1 being out. Med1 is to be given three times per day. S2 advised S2 called the pharmacy and was told the refill was two days early. S2 notified hospice and hospice said they would see what they could do. The following day, S2 arrived to work to find a liquid form of Med1 received by the pharmacy instead of tablets. S2 admitted the liquid form of Med1 was not given as staff only administered tablets. Although the Medication Administration Record was initialed as given, S1 could not confirm if Med1 was given on 12/12/22 for the 10pm or 6AM dose on 12/13/22, as Med1 had not been filled on 12/12/22. On 12/13/22, R1's family dropped off the over-the-counter Med1 instead for administration since there was a discrepancy with the pharmacy refill. This poses a potential health or personal rights risk to residents 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: Melinda HoffmannTELEPHONE: (559) -341-3274
LICENSING EVALUATOR NAME: Malia ThaoTELEPHONE: 559-470-9001
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2