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25 | ***Amended***
Licensing Program Analysts (LPAs) Rummonds and Felias arrived unannounced and met with Executive Director/ Administrator, Jessica Graham, and Connections for Living Director, Nathan Howland to conduct a Case Management - Incident visit. LPAs followed up on an Incident Report that occurred on 9/09/2023 and was received by Community Care Licensing (CCL) on 09/18/2023, which does not meet the regulation that requires facility to report incidents to CCL within 7 days. In addition, CCL received an SOC 341 (Suspected Dependent Adult/ Elder Abuse) that occurred on 10/14/2023 and was received by CCL on 10/16/2023.
Incident report dated 09/18/2023, Resident 1 (R1) did not receive a scheduled dose of morning medications. It was reported that the medication technician on duty was unaware that the resident had moved into a new apartment. Medication retraining is scheduled to be conducted this week (deficiencies cited, see LIC809D, regulations 87211(a)(1)(D) and 87465(a)(4)).
SOC 341 dated 10/16/2023, Resident 2 (R2) had a physical altercation with an outside agency caregiver. R2 reportedly was slapped across the face by their caregiver and showed signs of redness on their right cheek. Caregiver denied making physical contact with R2 and stated they had a verbal disagreement. Novato Police Department was called and arrived at facility at approximately 3PM to conduct interviews with staff and R2. R2 has a dementia diagnosis and was unable to provide details summarizing the incident to Novato PD. Facility has since suspended the Caregiver from involvement with the facility. R2's care manager and responsible party were informed of the incident.
**An immediate civil penalty in the total amount of $250.00 has been issued for repeat violations of regulations 87211(a)(1)(D) and 87465(a)(4). LIC421FC**
Exit interview conducted. Copy of report, LIC-809D, LIC421FC (Civil Penalty Assessment), LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/18/2023
Section Cited
CCR
87465(a)(4)
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7 | 87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. | 1
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7 | Facility to provide documentation showing that staff will be retrained. In service training to be conducted. Documentation to include: date of training, topics included, staff names, their job role, and signatures. Documentation to be submitted to CCL by POC due date of 10/18/2023 |
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14 | This requirement was not met as evidenced by: Based on document review, the licensee did not comply with the section cited above by R1 not being given medication as prescribed which poses an immediate health, safety or personal rights risk to persons in care. | 8
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14 | ***Civil Penalty assessed for a repeat violation of the same regulation within a 12 month period*** |
Type B
10/27/2023
Section Cited
CCR87211(a)(1)(D)
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7 | 87211 Reporting Requirements (a)...licensee shall furnish to the licensing agency..., including...:(1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of ...events specified in (A) through (D)...(D) Any incident which threatens | 1
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7 | Facility provided documentation showing that staff have been retrained. Deficiency cleared during visit. |
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14 | the welfare, safety or health of any resident...This requirement was not met as evidenced by: Based on Incident report, the licensee did not comply with the section cited above by not reporting timely which poses a potential health and safety risk to persons in care. | 8
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14 | ***Civil Penalty assessed for a repeat violation of the same regulation within a 12 month period*** |