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25 | Licensing Program Analyst (LPA) Joe Katrdzhyan conducted an unannounced site visit for the Required - 1 Year inspection. Today's visit is a continuation to the Required - 1 Year inspection conducted on 10/28/2021. Upon arriving at the facility, LPA met with Staff / Maria Rivera and was later joined by the Administrator / Maria Carlos who assisted with the visit. The facility is licensed to serve six (6) Developmentally Disabled Clients ages 18 - 59 years old, Ambulatory only. During today's visit, LPA used the infection control domain, rechecked the hot water temperature throughout the facility and reviewing client medications.
The following concerns were observed during today's visit;
- At 8:35AM, LPA was not screened for COVID upon entry by Staff #1 (S1). At 8:40AM, S1 was observed working inside the facility without wearing a face covering/mask.
- At 9:07AM, the hot water temperature was tested in the kitchen and measured at 122.2 degrees F. At 2:47PM, the hot water temperature was tested in bathroom #1 and measured at 121.2 degrees F. At 9:13AM, the hot water temperature was tested in bathroom #2 and measured at 120.4 degrees F.
- At 10:32AM, LPA reviewed medications for Client #1 (C1) and observed that Zolpidem Tartrate 10MG Tablet (Bedtime) was not administered to C1 on 10/24/21 (was in the bubblepack) but initialed on the Medication Administration Record (MAR) as if it was administered to C1.
- At 10:37AM, LPA observed Promethazine DM 6.25-15MG/5ML (PRN) was missing from the facility for C1.
The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D)
An exit interview was conducted and a copy of this report was provided to the Administrator along with the Appeals Rights. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/06/2021
Section Cited
CCR
80072(a)(2)
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7 | Personal Rights. Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by: | 1
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7 | Administrator will ensure that facility is
following California Dept of Public Health and
CCLD requirements. Administrator will provide
a written statement stating that facility staff
were re-trained and will comply with CDSS
requirements and regulations, and will maintain
a safe and healthful environment for residents
and staff. |
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14 | At 8:35AM, LPA was not screened for COVID upon entry by Staff #1 (S1). At 8:40AM, S1 was observed working inside the facility without wearing a face covering/mask.
This poses an immediate health, safety risk to persons in care. | 8
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Type A
11/05/2021
Section Cited
CCR80088(e)(1)
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7 | Buildings and Grounds. Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).
This requirement is not met as evidenced by; | 1
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7 | Facility staff adjusted the hot water temperature and LPA re-tested the hot water temperature throughout the facility and it was measured within Title 22 Regulation guidelines.
***Citation was cleared at the time of visit and no further action is needed*** |
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14 | At 9:07AM, the hot water temperature was tested in the kitchen and measured at 122.2 degrees F. At 2:47PM, the hot water temperature was tested in bathroom #1 and measured at 121.2 degrees F. At 9:13AM, the hot water temperature was tested in bathroom #2 and measured at 120.4 degrees F. This poses an immediate health, safety risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/06/2021
Section Cited
CCR
80075(b)
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7 | Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement is not met as evidenced by;
At 10:32AM, LPA reviewed medications for Client #1 (C1) and observed that Zolpidem Tartrate 10MG Tablet (Bedtime) was not | 1
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7 | Administrator will schedule an in-service training on Medication Management for all facility staff in charge of medication administration. A copy of the materials discussed during the training and signatures of all staff present must be forwarded to the CCL office by the POC due date. |
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14 | administered to C1 on 10/24/21 (was in the bubblepack) but initialed on the Medication Administration Record (MAR) as if it was administered to C1.
This poses an immediate health, safety risk to persons in care. | 8
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Type A
11/06/2021
Section Cited
CCR80075(b)(5)(B)
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7 | Health Related Services. Once ordered by the physician the medication is given according to the physician's directions.
This requirement is not met as evidenced by; At 10:37AM, LPA observed Promethazine DM 6.25-15MG/5ML (PRN) was missing from the facility for C1. This poses an immediate health, | 1
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7 | Administrator will ensure missing PRN medication Promethazine DM 6.25-15MG/5ML is obtained or a discontinue order is provided for C1 (by picture) to CCL by POC due date. |
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14 | safety risk to persons in care. | 8
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