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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800165
Report Date: 12/05/2022
Date Signed: 12/05/2022 04:45:59 PM


Document Has Been Signed on 12/05/2022 04:45 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:AUSTIN SMALL ARIZONA FAMILY HOME IIFACILITY NUMBER:
361800165
ADMINISTRATOR:AUSTIN, ALEXANDRIAFACILITY TYPE:
735
ADDRESS:17049 LA VESU ROADTELEPHONE:
(909) 823-2624
CITY:FONTANASTATE: CAZIP CODE:
92337
CAPACITY:6CENSUS: 3DATE:
12/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Sabrina Weddles TIME COMPLETED:
04:48 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Anna Bueno and Amber Coleman conducted an unannounced visit to the facility for the purpose of conducting a case management visit. In November 2022, CCL received two reports related to medication documentation. LPA's were greeted by staff member (S1) Sabrina Weddles who invited LPA's inside. LPA's and S1 discussed the purpose of the visit.S1 contacted Administrator on the phone during visit to answer LPA's questions.

R2's medication record indicated the resident is prescribed to have a medication administered three times a day. LPA observed that only 2 signatures per day were present. Administrator explained that the afternoon medication is PRN; which means R2 is given the medication when they ask for it. However, a review of the medication record shows that the medication is to be administered three times daily and no refusals were indicated from R2. Medication dispensed on 11/2/2022 shows eight tablets that were not administered. Additionally, for the dates 12/2/22 to 12/5/22 according to the records the medication was only given to R2 twice a day, missing the afternoon dosage.

This poses an immediate health and safety risk to the residents in care. Refer to LIC809-D for deficiency cited. A copy of this report, LIC809-D and appeal rights were proved to facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022
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 12/05/2022 04:45 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: AUSTIN SMALL ARIZONA FAMILY HOME II
FACILITY NUMBER: 361800165

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/07/2022
Section Cited

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Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This is requirement was not met as evidenced by
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a review of medication records indicated the medication was to be administered 3 times a day. However, eight of 28 medications remained unadministered.
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Per Licensee, they are waiting for a scheduled training date from the resident's pharmacy.

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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022
LIC809 (FAS) - (06/04)
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