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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700525
Report Date: 06/19/2023
Date Signed: 06/19/2023 11:09:09 AM


Document Has Been Signed on 06/19/2023 11:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ALMOND HEIGHTSFACILITY NUMBER:
342700525
ADMINISTRATOR:MACDONALD, STEPHENFACILITY TYPE:
740
ADDRESS:8685 GREENBACK LNTELEPHONE:
(916) 542-7988
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:145CENSUS: 102DATE:
06/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Director of Health, Eva BowlinTIME COMPLETED:
11:30 AM
NARRATIVE
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On 06/19/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 06/04/23. LPA met with Director of Health (DOH) , Eva Bowlin and explained reason for visit.

Special Incident Report (LIC 624) submitted by facility on 06/05/23 to CCL stated that R1 was send to hospital on 06/04/23 around 8.30am, after R1 was given wrong medications by staff. Incident report indicated that R1 was given medications, Fenofibrate 54mg- 1 tablet, and Fluoxetine 10 mg- 1 tablet which were NOT prescribed by R1s physician. Staff notified immediately facility’s management regarding the medication error and facility send out R1 to hospital to seek medical care. R1 came back to the facility same day with no changes to their health and they were back to their baseline. Facility notified R1s physician and responsible party on 06/04/23 regarding medication error.

Based on incident report, staff interviews and medication record review from the facility, R1 was given medications, Fenofibrate 54mg- 1 tablet, and Fluoxetine 10 mg- 1 tablet by mistake. It was determined that facility administered wrong medications to R1 which poses a immediate heath and safety risks to residents in care.

Deficiencies are cited on LIC809D, pursuant to California Code of Regulations, Title 22, Section 80075(b)(5)(B) and documented on the attached LIC809D.

The report was reviewed, appeal rights and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/19/2023 11:09 AM - 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ALMOND HEIGHTS
FACILITY NUMBER: 342700525

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2023
Section Cited
CCR
80075(b)(5)(B)

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80075 Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Licensee/Administrator agreed to submit a self-certification in regard to providing medication training for all staff regarding medication administration and submit proof to LPA by POC date- 06/20/23.

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Based on record review from the facility, on 06/04/23, R1 was given medications, Fenofibrate 54mg- 1 tablet, and Fluoxetine 10 mg- 1 tablet by mistake from staff and these medications were not ordered by R1s physician which poses an immediate health and safety 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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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