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13 | On 1/29/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit to deliver findings. LPA introduced self, stated purpose of visit, and allowed entrance by staff. Administrator was not available to conduct today's visit.
This department has investigated the above allegation. During the course of the investigation, LPA toured the facility, conducted interviews, and reviewed documentation.
Based on LPA observation of expired food in facility in both the pantry and refrigerator during facility tour on 12/14/2024. During record review, LPA observed documentation showing staff have insufficient hours of annual training for medication. The preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.
Exit interview conducted and a copy of this report was provided for facility records. |
| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
02/02/2024
Section Cited
CCR
87555(a) | 1
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7 | (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National | 1
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7 | Expired food was removed and thrown away during visit conducted on 12/14/24. Licensee to go through all food and remove expired food and ensure food is checked periodically to remove expired items. POC CLEARED AT TIME OF VISIT |
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14 | Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. ***This was not met as evidenced by during LPA tour of facility, LPA observed expired food in the refrigerator and pantry. | 8
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Type B
03/27/2024
Section Cited
HSC
1569.69(b) | 1
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7 | Employees assisting residents with self-administration of medication; training requirements (b)Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self- | 1
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7 | Licensee/Administrator to conduct self audit and ensure that staff are receive minimum of 8 hours annual training in medication. Proof of correction and documentation to be submitted to Fresno Regional Office |
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14 | administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. ***This was not met as evidenced by during record reviewLPA observed documentation showing staff have insufficient hours of annual training for medication. | 8
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14 | no later than POC due date. |
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13 | On 1/29/24, Licensing Program Analyst (LPA) M. Medina conducted an unannounced subsequent complaint visit to deliver findings. LPA introduced self, stated purpose of visit, and allowed entrance by staff. Administrator was not available to conduct today's visit.
This department has investigated the above allegations. During the course of the investigation, LPA toured the facility, conducted interviews, and reviewed documentation. During facility tour and unannounced visits to facility on 10/21/23, 10/26/23, 12/14/23, and 12/18/23, LPA observed medication to be locked and secured, pool was inaccessible to residents, and staff were present at time of unannounced visits. The department has insufficient information regarding the above allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or disprove that the allegation occurred therefore the allegations are UNSUBSTANTIATED.
No deficiencies cited. |
| Unsubstantiated | Estimated Days of Completion: |
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