NARRATIVE |
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25 | Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Salote Lewis and explained the purpose of the visit.
During a visit on 9/21/23, LPA Moleski reviewed residents' medication administration records (MARs). LPA Moleski observed the initials "IN" signing off on medication administrations on September 15 through September 17, 2023.
During a visit on 9/21/23, LPA Moleski interviewed a staff member (S1) about who the initials belonged to. S1 said they belonged to an individual (S2) who filled in for S1 while S1 was out. S1 said he worked with S2 for one day, and S2 worked on their own afterward.
During a visit on 9/21/23, LPA Moleski interviewed a resident (R1) who said an individual (S2) worked as a caregiver for a total of three days at this facility.
During a visit on 9/21/23, LPA Moleski reviewed the Licensing Information System (LIS). The only individuals associated to this facility as of 9/21/23 were facility administrator Salote Lewis and S1.
During an interview on 9/26/23, Lewis said this individual (S2) works on the weekends. Lewis provided this individual's full legal name. Lewis said S2 has a criminal record clearance.
During an interview, on 9/21/23, S1 said that R2 suffered a fall on or around August 21, 2023, and was hospitalized until September 1, 2023. During interviews on 9/21/23, R1 and R2 both said that R2 had suffered a fall. LPA Moleski did not receive an incident report regarding R2's fall or hospitalization. [continued on 809-C] |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
09/27/2023
Section Cited
CCR
87355(e)(2)
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7 | Criminal Record Clearance: "(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: ...
...(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or"
This requirement was not met as evidenced by: | 1
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7 | Licensee agrees to associate S2 by the POC due date. Licensee agrees to email LPA Moleski confirming S2 has been associated.
vincent.moleski@dss.ca.gov |
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14 | Based on record review and interviews, an individual who was not cleared worked in this facility for at least three days, which poses an immediate health and safety risk. | 8
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Type B
10/03/2023
Section Cited
CCR87211(a)(1)(D)
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7 | Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident."
This requirement was not met as evidenced by: | 1
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7 | Licensee agrees to review Title 22 reporting requirements and to write a statement of acknowledgment that these requirements have been reviewed. Licensee agrees to email LPA Moleski a copy of this statement.
vincent.moleski@dss.ca.gov |
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14 | Based on interviews and record review, R2 fell and was hospitalized between 8/21/23 and 9/1/23, and an incident report was not received reporting this event, which poses a potential health and safety risk. | 8
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