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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700670
Report Date: 10/27/2020
Date Signed: 10/27/2020 04:29:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:LATER YEARS SENIOR CARE HOMEFACILITY NUMBER:
342700670
ADMINISTRATOR:ORNELLAS, MARITESFACILITY TYPE:
740
ADDRESS:14 ARARAT CTTELEPHONE:
(916) 538-6096
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 5DATE:
10/27/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marites OrnellasTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/27/2020 at 12:30pm. LPA spoke with Marites Ornellas and stated the purpose of the visit. This is a subsequent visit to complaint 27-AS-20200309100958.

During the investigation, LPA observed that the facility staff was using a Medication Administration Record (MAR) to log dates and times when R1 was receiving assistance with administration of prescribed medications.
LPA observed that the MARs was missing information:
-R1’s name on one document
-Medication had been missed on several days
-No start date for other medications.
LPA observed that the Centrally Stored Medication and Destruction Record was missing information:
-Start date for one medication.

LPA observed that on 3/10/2020, Resident Records was cited during a Case Management Visit.

On 5/23/2020, the Administrator, admitted there was butt paste in stock and it was used on R1 the same night after returning from the hospital. The Administrator then requested the family to provide the over the counter cream for R1. Once the family purchased the cream it was used on R1 by S3. LPA did not observe that R1 had an order for the cream from an appropriately skilled professional.

LPA also received and reviewed documentation of the initiation of hospice services and MAR list for R2. In reviewing facility documentation, LPA observed that R2 is receiving hospice care services and was prescribed a barrier cream to prevent skin breakdown and dryness. LPA did not observe evidence that facility staff used R2's prescribed barrier cream medication on R1.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LATER YEARS SENIOR CARE HOME
FACILITY NUMBER: 342700670
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2020
Section Cited

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87506(b)(1-17) (A-F)
Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident…readily available to… licensing agency staff.
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This requirement is not met as evidenced by: Based on review of resident files and observation of documentation, the licensee did not ensure resident records are completed, signed, and dated as required by Title 22 Regulations. This violation poses a potential health, and safety risk to residents in care.
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You are hereby issued an immediate civil penalty in the amount of $250.00 for a repeat violation of the same subsection within a 12-month period.

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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: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: LATER YEARS SENIOR CARE HOME
FACILITY NUMBER: 342700670
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2020
Section Cited

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Incidental Medical and Dental Care
For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information...
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This requirement is not met as evidenced by: Based on a review of documentation, medical records, and interviews, the facility staff used an over the counter medication on R1 without a prescription order from a licensed skilled professional. This violation poses an immediate health, and safety risk to residents in care.
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Type A
10/28/2020
Section Cited

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Incidental Medical and Dental Care
The following requirements shall apply to medications which are centrally stored:

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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This requirement is not met as evidenced by: Based on interviews, the facility staff stored R1’s medication in a drawer in the residents’ room that was not locked. This violation 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: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: LATER YEARS SENIOR CARE HOME
FACILITY NUMBER: 342700670
VISIT DATE: 10/27/2020
NARRATIVE
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The investigation revealed that there was no prescription for the cream(s) or an order for the cream(s) to be used on R1.

In addition, Administrator kept the medication Latanoprost in a drawer that was not centrally stored or locked.

As a result of the investigation, the preponderance of evidence has been met. Therefore, the deficiencies will be cited during this case management visit.

A previous Case Management licensing report was issued on 3/10/2020 giving notice of the same violation for resident records. The following civil penalty in the amount of $250.00 shall be assessed today for repeating the same violation within 12 months. The Licensee was provided a copy of the issued immediate civil penalty (LIC421FC) during this visit.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; additional civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted with Marites Ornellas via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Victoria BrownTELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4