NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 | Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit to follow up on an incident reports sent to licensing dated on 6/25/22, 7/22/22, and 7/23/22. The incidents involve six (6) residents that were missing narcotic medications. LPA met with Administrator Christopher Tanabe and explained the reason for the visit.
LPA Gardner reviewed medications, medication logs, and conducted interviews with staff. LPA Gardner found that the Administrator has interviewed staff members who were on shift when the medication went missing. The Administrator had each staff member write down a written statement of what happened on the days in question. The Administrator informed state licensing of each incident and filed police reports for each incident. There are cameras that are in the process of being installed in the facility. The facility is going to ensure there is only one set of keys for the medication cabinet per shift. The facility is going to create a sign in/sign out sheet for the medication cabinet keys. As of today, 7/29/2022, the Administrator is unsure of where the narcotic medication is at and/or who took the narcotic medication.
The facility will be receiving a citation for not supervising the staff and not establishing polices to ensure the residents medications do not go missing. The facility will also be receiving a citation for not providing medication safety and policy training to ensure staff has the knowledge and skill required to provide resident care.
Additionally, during today’s visit, LPA Gardner found unlocked medication in the kitchen on top of the microwave, in an unlocked kitchen cabinet, and on top of the medication cabinet. This facility will be issued a citation for not locking the medication.
Based on the observations made during today’s visit, three (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
07/30/2022
Section Cited
CCR
87205(a)
| 1
2
3
4
5
6
7 | 87205. Accountability of Licensee Governing Body. (a)The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. | 1
2
3
4
5
6
7 | The licensee has agreed to read regulation 87205 entirely and send LPA a self-certify letter via email, fax, or post mail that the regulation was read and understood. The licensee has agreed to send a written plan of how the medication will be supervised to ensure residents medications do not go missing. |
 | 8
9
10
11
12
13
14 | This requirement was not met based on interviews and documentation review. The licensee did not comply with the section cited above by not supervising the staff and not having polices in place to ensure the residents medications do not go missing. | 8
9
10
11
12
13
14 | |
Type A
07/30/2022
Section Cited
CCR87465(h)(2)
| 1
2
3
4
5
6
7 | 87465. Incidental Medical and Dental Care. (h)The following requirements shall apply to medications which are centrally stored:(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. | 1
2
3
4
5
6
7 | The licensee has agreed to read regulation 87465 entirely and send LPA self-certify letter via email, fax, or post mail that the regulation was read and understood. The licensee has agreed to lock the medications in the medication cabient. |
| 8
9
10
11
12
13
14 | This requirement was not met based on observation. The licensee did not comply with the section cited above by having unlocked medication in the kitchen on top of the microwave, in an unlocked kitchen cabinet, and on top of the medication cabinet. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/12/2022
Section Cited
CCR
87411(e)
| 1
2
3
4
5
6
7 | 87411.Personnel Requirements - General.In facilities licensed for sixteen (16) or more, the requirements of Section 87411(d) shall be met with planned on the job training program that utilizes orientation, skill training and continuing education. | 1
2
3
4
5
6
7 | The licensee has agreed to read regulation 87411 entirely and send LPA self-certify letter via email, fax, or post mail that the regulation was read and understood. The licensee has agreed conduct a medication training with the staff. The licensee has agreed to send LPA proof that a medication safety and policy training has been scheduled. The license has also agreed to send LPA proof that the class was completed. |
| 8
9
10
11
12
13
14 | This requirement was not met based on interview with Administrator admitting the staff had not been trained on medication safety and policies. The licensee did not comply with the section cited above by not training the staff on medication safety and polices to ensure staff has the knowledge and skill required to provide resident care. | 8
9
10
11
12
13
14 | |
| 1
2
3
4
5
6
7 | | 1
2
3
4
5
6
7 | |
| 1
2
3
4
5
6
7 | | 1
2
3
4
5
6
7 | |