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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005010
Report Date: 02/09/2023
Date Signed: 02/09/2023 11:36:07 AM


Document Has Been Signed on 02/09/2023 11:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:ALL SEASONS, LLCFACILITY NUMBER:
347005010
ADMINISTRATOR:ANATOLIY MOLITVENIKFACILITY TYPE:
740
ADDRESS:8731 CENTRAL AVENUETELEPHONE:
(916) 776-6665
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 5DATE:
02/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Staff ,Alma CaniedoTIME COMPLETED:
11:50 AM
NARRATIVE
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On 02/09/2023, Licensing Program Analyst (LPA) Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 01/29/23 for resident (R1) for medication error. LPA met with staff Alma Caniedo and explained reason for visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask.

After staff interviews and records reviewed, it was determined that, staff (S1) dispensed the wrong medication to a resident in care. LPA Bains had initially received an incident report on a LIC624 on 02/02/23 regarding the medication error involving resident R1 for date- 01/29/23. Through documentation reviewed, it was determined S1 distributed medication, Levothyroxine, 50 mcg to R1 in error which was not belong to R1. The facility documented the medication error and did seek medical observation and treatment for R1 following the medication error.

Deficiency is cited per California Code of Regulations, Title 22, and listed on LIC 809D. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties.

Exit interview conducted. Appeal rights provided. Copy of the report left at facility.






SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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 02/09/2023 11:36 AM - 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
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: ALL SEASONS, LLC
FACILITY NUMBER: 347005010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited

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 87465(a)(5)-- Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by:
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Licensee agrees to conduct a medication distribution training for all staff and will provide LPA with training information after conducted with staff signatures. Administrator has already trained the staff (S1) who administered the medication to R1 by error. All POC documents are due by 02/10/2023.
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Based on the fact that staff gave R1 the wrong medication to R1 on 01/29/23, which poses an immediate health and safety risk to residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
LIC809 (FAS) - (06/04)
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