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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347005010
Report Date: 04/15/2024
Date Signed: 04/15/2024 11:23:52 AM


Document Has Been Signed on 04/15/2024 11:23 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 6DATE:
04/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Operations Director, Galina Chikivchuk TIME COMPLETED:
11:30 AM
NARRATIVE
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On 04/15/24, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility to conduct a Case Management visit regarding an incident that occurred on 03/15/24 for resident (R1) for medication error as reported by facility on 03/21/24 by Incident Report ( LIC624). LPA met with Operations Director, Galina Chikivchuk and explained the reason for visit.

After staff interviews and records reviewed, it was determined that staff (S1) gave extra medication dose of Divalproex Sodium during med pass on 03/15/24 around 8am. Incident report stated that S1 accidentally added an extra pill of Divalproex Sodium in R1s medication box during morning med pass on 03/15/24 around 6am while dispensing the morning medications for R1. Facility reported this medication error to R1s family, physician and other agencies as required. Incident Report indicated that R1s doctor ordered a hold on the Divalproex Sodium until further notice after this incident on 03/15/24.

Based on this information, 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: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
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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Document Has Been Signed on 04/15/2024 11:23 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ALL SEASONS, LLC
FACILITY NUMBER: 347005010

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2024
Section Cited
CCR
87465(c)(2)

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87465-Incidental Medical and Dental Care-(c)-If the resident's physician has stated in writing that the resident is unable to…(2)Once ordered by the physician the medication is given according to the physician's directions…..this requirement is not met as evidence by;
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Licensee/Administrator agrees to conduct medication distribution training for all staff and will provide LPA with training information. Administrator has already trained the staff (S1) who administered the medication to R1 by error and other staff. All POC documents are due by 04/16/24.
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Based on the gathered information, it has been concluded that staff (S1) gave 1 extra tablet of Divalproex Sodium to R1 on 03/15/24 around 8AM, 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: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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