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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701230
Report Date: 10/24/2023
Date Signed: 10/24/2023 02:48:56 PM


Document Has Been Signed on 10/24/2023 02:48 PM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:SACRAMENTO SENIOR LIVINGFACILITY NUMBER:
342701230
ADMINISTRATOR:LEWIS, SALOTEFACILITY TYPE:
740
ADDRESS:6825 BENDER CTTELEPHONE:
(510) 710-5707
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:6CENSUS: DATE:
10/24/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Eliesa QioleleTIME COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit in order to address deficiencies discovered during a complaint investigation. LPA Moleski spoke with facility administrator Salote Lewis over the phone and explained the purpose of the visit.

During the course of a complaint investigation, LPA Moleski interviewed a staff member (S1). S1 told LPA Moleski that S1 flushed an unknown quantity of a resident's (R1) medication on an unknown date.

During a complaint investigation visit on October 5, 2023, LPA Moleski observed in R1’s centrally stored medication records that R1 started a 30-capsule bottle of medication on September 2, 2023. This medication was not listed on R1’s MARs for the month of September. LPA Moleski reviewed hospital discharge orders for R1 from a hospital visit dated August 21, 2023 to September 1, 2023 which discontinued the medication. On R1’s MARs for October 2023, R1 was given daily doses of the medication from October 1 to October 5, according to the MARs. During the same visit on October 5, 2023, LPA Moleski interviewed a staff member (S1). S1 said R1 was not given doses of the medication from October 1, 2023 through October 3, 2023, and admitted to falsely marking the MARs as if medication had been given, though none was. S1 said there was no new start order for the medication. LPA Moleski interviewed a second staff member (S2). S2 said R1 had been given doses of the discontinued medication on October 4, 2023 and October 5, 2023. During the same visit on October 5, 2023, LPA Moleski observed that only two capsules of the medication remained of the 30-capsule bottle. Based on doses signed off in R1’s MARs, a minimum of 25 capsules should have remained as of October 5, 2023. S1 said S1 flushed an unknown quantity of capsules at an unspecified date. S1 said there were no witnesses to this act. R1’s medication destruction records were blank as of October 5, 2023.

This facility is being cited per 22 CCR Section 87465(i). An exit interview was held with Lewis. Appeal rights and a copy of this report were left with staff member Eliesa Qiolele.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
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 10/24/2023 02:48 PM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: SACRAMENTO SENIOR LIVING
FACILITY NUMBER: 342701230

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2023
Section Cited
CCR
87465(i)

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"(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:"

This requirement was not met as evidenced by:
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Licensee agrees to conduct a staff training regarding medication destruction. Licensee shall send LPA Moleski a sign-in sheet for this training and send a copy to LPA Moleski.
vincent.moleski@dss.ca.gov
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Based on observation and interview with S1, S1 destroyed an unknown amount of R1's medications without witnesses, and without the presence of the facility administrator, and without recording the destruction as required, which poses an immediate health and safety risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2