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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004571
Report Date: 05/25/2023
Date Signed: 05/25/2023 04:47:40 PM

Document Has Been Signed on 05/25/2023 04:47 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:LADIORAY HOME INC.FACILITY NUMBER:
347004571
ADMINISTRATOR:MINA, LUZ M.FACILITY TYPE:
735
ADDRESS:4510 CAREYBACK AVENUETELEPHONE:
(916) 428-0392
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 4CENSUS: 4DATE:
05/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Luz MinaTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit regarding a facility action report from Alta California Regional Center (ACRC). LPA Moleski met with administrator Luz Mina and explained the purpose of the visit.

ACRC's facility action report stated that on May 4, 2023, ACRC representatives observed a dose of medication left in a bubble pack for R1 for May 3, 2023, but the R1's MARs were signed off as if there had been a dose given to the resident.

Mina told LPA Moleski that a pill had gotten stuck in the bubble pack and that the staff member signed off on the MARs. Mina said the pill has since been destroyed.

ACRC's facility action report also stated that R2's PRN authorization letter showed the resident is unable to determine their need for PRN or communicate their symptoms. According to the report, Mina told ACRC representatives that she had not been contacting the resident's doctor prior to giving PRN medications.

LPA Moleski reviewed the resident's PRN authorization letter, which stated that the resident cannot determine their own need for prescription or nonprescription PRN, and cannot communicate their symptoms or a need for nonprescription medication. A line on the letter states "must contact physician before each dose." This line had been crossed out in pen.

Mina told LPA Moleski that she had not been contacting the doctor before giving the PRN medication.

This facility is being cited per 22 CCR 80075(b) and 80075(b)(6)(A). An exit interview was conducted with Mina. Appeal rights and a copy of this report were left with Mina.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2023
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 05/25/2023 04:47 PM - It Cannot Be Edited


Created By: Vincent Moleski On 05/25/2023 at 04:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LADIORAY HOME INC.
FACILITY NUMBER: 347004571

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
80075(b)

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Health Related Services: "(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications."

This requirement was not met as evidenced by:
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Licensee agrees to send LPA Moleski training records regarding medication administration by POC due date.
vincent.moleski@dss.ca.gov
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Based on ACRC's facility action report and based on interview with administrator Mina, a medication dose was missed for R1.
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Type B
06/09/2023
Section Cited
CCR80075(b)(6)(A)

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Health Related Services: "(6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met:

(A) Facility staff shall contact the client's physician prior to each dose, describe the client's symptoms, and receive direction to assist the client in self-administration of that dose of medication."

This requirement was not met as evidenced by:
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Licensee agrees to send LPA Moleski training records regarding PRN administration by POC due date.
vincent.moleski@dss.ca.gov
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Based on record review and interview with administrator Mina, R2's physician was not contacted as required prior to administration of PRN medication.
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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 Richardson
LICENSING EVALUATOR NAME:Vincent Moleski
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023


LIC809 (FAS) - (06/04)
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