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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002983
Report Date: 04/05/2024
Date Signed: 04/05/2024 12:54:59 PM

Document Has Been Signed on 04/05/2024 12:54 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:LOMOND HOMEFACILITY NUMBER:
345002983
ADMINISTRATOR/
DIRECTOR:
SORONGON, ESPERANZAFACILITY TYPE:
734
ADDRESS:4841 LOCH LOMOND DRTELEPHONE:
(650) 580-3896
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 5CENSUS: 5DATE:
04/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Shiryl Mishra and Donna ValenciaTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the semi-annual monitoring report conducted by Department of Developmental Services (DDS) on March 13, 2024. LPA met with Administrator and Licensee and explained the purpose of the visit.

Upon reviewing the report, LPA observed the following deficiency observed by DDS during their time of visit. The report stated C1 received a new medication order in February 2024 but based on file review of centrally stored log, it did not list C1's new medication order.

LPA, Licensee and Administrator discussed the incident that the new medication was inputted into the Medication Administration Record but just not in the log which list all the centrally stored medications. LPA was informed this error was due to the isolation when the facility tested positive for COVID-19.

Upon reviewing the report, LPA observed the following deficiency observed by DDS during their time of visit. The report stated C2 has a PRN order but the medication was not centrally stored.

Administrator informed LPA that the reason the medication was not centrally stored is because the medication has not been administered to C2 since November 2022. Administrator stated the pharmacy they are contracted with, is able to "stat" medication orders and have it ready within an hour if needed. Licensee informed LPA PRN replacement was not received due the excessive PRN medication waste when expired as refills has been made in the past, but not being administered.

Exit interview and a copy of the report provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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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