347003884-12-11-2023-27-AS-AVIA-CYEV2A-20231211150249

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003884
Report Date: 12/11/2023
Date Signed: 12/11/2023 03:03:05 PM

Document Has Been Signed on 12/11/2023 03:03 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	TAHOE, THE		FACILITY NUMBER:	347003884
ADMINISTRATOR:	DESCARGAR, BERNADETTE		FACILITY TYPE:	740
ADDRESS:	8708 SECKEL COURT		TELEPHONE:	(916) 686-5715
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 5	DATE:	12/11/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Bernadette Descargar		TIME COMPLETED:	03:15 PM

NARRATIVE

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On 12/11/23, at 10:15am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility to conducted an unannounced Case Management-Annual continuation visit to continue with the Annual visit initiated on 12/6/23. The LPA met with Bernadette Descargar, Administrator on record, and explained the purpose of today's visit. During this visit there are 5 residents in care with 3 staff on duty.

During this inspection, LPA conducted an audit of facility files, 5 resident files, and 6 staff files for regulatory compliance. All staff noted on LIC 500 have criminal background clearances and are associated to this facility. LPA attempted 2 resident interviews, however, residents were not available for interviews. LPA also completed 2 staff interviews. 5 out of 5 resident files reviewed contained all required contents including updated admission agreements, medical assessments, and updated appraisal forms as required. 5 out of 5 staff files reviewed contained all required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required trainings. Facility’s liability insurance is current per regulatory requirements. The facility is current on annual license fees. LPA reviewed facility’s disaster plan to ensure regulatory compliance. Facility conducts quarterly fire drills.

Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy. First aid kit was observed to have adequate supplies and accessible to staff. The facility maintains for each resident Centrally Stored Medication, Destruction Record and PRN Log. LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed facility to have sufficient equipment and supplies to meet activity program needs of residents in care.

{Con't LIC809-C}

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TAHOE, THE	FACILITY NUMBER: 347003884
	VISIT DATE: 12/11/2023

NARRATIVE

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{Con't from LIC809}

Per California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

The following deficiencies were observed during today’s inspection:

· During medication review of 3 residents, LPA observed prescribed PRN medications in 2 of the residents do not contain pharmacy label. Additionally, 1 out of 2 bottles of Trazadone 100mg in one of the residents’ medication contains the wrong label which does not match with the current physician’s prescription. Per label reads Trazadone 100mg to be taken 2 tablets by mouth. Per review of the physician’s order, the prescription reads to take 2 and a half tablets by mouth. Per staff interview, staff have been giving the Trazadone as prescribed and that staff were trying to finish that particular bottle of Trazadone.

· During medication review, LPA observed that 1 out of 3 residents were being given the wrong dosage of the prescribed PRN. Per review of resident’s physician order, this resident was supposed to be receiving Docusate Sodium 250mg by mouth one time a day for constipation. However, per medication review, LPA observed that the Docusate Sodium is at 240mg. Per staff interview, staff have been giving the Docusate Sodium 240mg since the facility received this medication.

An exit interview was held with Bernadette Descagar, Administrator, and a copy of this report and appeal rights were provided to the facility.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/21/2024 03:29 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/21/2024 02:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TAHOE, THE	FACILITY NUMBER: 347003884
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above. During medication review, LPA observed 1 out of 2 bottles of prescription medication of one resident contains the wrong label which does not match with the current physician’s prescription, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/18/2023
	Plan of Correction
1 2 3 4	Corrected during this visit: Licensee conducted medication destruction to one of two bottles of medication. Licensee to submit a statement of understading of the CCR 87465(h)(4) to the Department by POC due date. {This is an amended version of the report originally created on 12/18/2023}

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/11/2023 03:03 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TAHOE, THE	FACILITY NUMBER: 347003884
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(e)(2)

(e) 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. (2) The exact dosage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee did not comply with the section cited above where during medication review, LPA observed that 1 out of 3 residents were being given the incorrect dosage of a prescribed PRN, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/12/2023
	Plan of Correction
1 2 3 4	Licensee to obtain the correct dosage of resident's medication by POC due date. Licensee to submit a photo of the correct medication to the Department by POC due date. Licensee to submit a statement of understanding of CCR 87465(e)(2) to the Department by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Richardson	TELEPHONE: (916) -26-4700
LICENSING EVALUATOR NAME: Arvin Villanueva	TELEPHONE: 916-558-2130
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

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