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32 | During interviews with the staff, two (2) out of five (5) staff corroborated the allegation. One of the staff interviewed stated that from their understanding that staff training had been conducted up through 2022, however afterwards the training did not continue to be conducted. Another staff interviewed stated that although a client uses a dry-powder inhaler, there was no documentation available that annual retraining by a licensed professional had been conducted as required by Title 22 regulations. During review of the medications, physician's orders were on file for a dry-powder inhaler for two (2) separate clients and there was no documentation of staff training on file.
In regards to the allegation that "Staff did not follow reporting requirements," it is alleged that there was an incident involving a car accident amongst a staff members and another client that was not reported. During interviews with the staff, one (1) out of five (5) corroborated the allegation. Most staff interviewed stated that they were aware that there was an incident involving a car crash with clients while a staff was driving them, but were not aware of the details of the incident or whether it was reported. Another staff interviewed confirmed that the incident did occur and was cross reported to ELARC. During review of the incident reports submitted, to Community Care Licensing Division (CCLD), no report was received for the incident which occurred on 9/18/2024.
Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 1 is being cited on the attached LIC9099D.
Exit interview was held and a copy of the report along with the appeal rights were provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
12/17/2024
Section Cited
CCR
80061(b)(1)(E) | 1
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7 | (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. (...) and a written report within 7 days (...) (1) Events reported shall be the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. | 1
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7 | ***POC Cleared During Visit** Administrator is to ensure that all all incident reports are submitted on time at all times. Administrator is to create an incident report for the incident and submit it to CCLD by the POC due date. |
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14 | This regulation was not met as evidenced by:
Based on observation and record review, LPA determined that an incident report had not been submitted for a car crash involving clients on 9/18/2024, which poses a potential health and safety concern for clients in care. | 8
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Type B
12/31/2024
Section Cited
CCR
80075(b)(1)(A) | 1
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7 | (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with (...) dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must receive training from a licensed professional. Professional training must be conducted and documented at least once per year. | 1
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7 | Administrator is to ensure that staff are adequately trained on medications procedures and that staff receive training by a licensed professional on dry-powder inhaler use at least once per year. Administrator is to conduct retraining amongst staff and submit the training materials, name of the trainer, |
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14 | Based on interview and record review, LPA determined that training from a licensed professional had not been held on dry-powder inhaler use by a licensed professional within the past year, which poses a potential health and safety risk for clients in care. | 8
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14 | and a list of attendees of the training to the LPA by the POC due date. |