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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374600800
Report Date: 04/21/2023
Date Signed: 04/21/2023 03:26:53 PM


Document Has Been Signed on 04/21/2023 03:26 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:WESLEY PALMSFACILITY NUMBER:
374600800
ADMINISTRATOR:GESKE, BENFACILITY TYPE:
740
ADDRESS:2404 LORING STREETTELEPHONE:
(858) 274-4110
CITY:SAN DIEGOSTATE: CAZIP CODE:
92109
CAPACITY:511CENSUS: 317DATE:
04/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Assistant Rowena Lomboy and Director of Resident Health Services Aurora GaliciaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Assistant Rowena Lomboy and Director of Resident Health Services Aurora Galicia.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office on 03/29/2023. According to the LIC624: in late March 2023, there were occasions when staff did not give (i.e., missed giving) Resident #1 (R1) their prescribed antibiotic medication. [See LIC 811 Confidential Names List for a description of person identifiers used in this report]. Staff first discovered the medication errors on 03/25/2023 and notified R1’s responsible party and physician that same day. The missed doses did not result in any visible adverse health consequence for R1.

During today’s visit, LPA performed a brief facility tour and attempted a welfare check on R1, but R1 was off-site on an outing during LPA's visit. LPA interviewed pertinent staff and reviewed relevant records.

Per their latest LIC602 Physician’s Report: to the stock questions of whether R1 was able to store and administer their own prescription medications, R1’s doctor checked the “Yes” boxes. However, the same doctor also diagnosed R1 with “Mild Cognitive Impairment.” Staff interviews revealed that, in practice: staff stored R1’s prescribed medications, R1 required staff help with safely taking their medications, and R1 was paying licensee for medication management services.

[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 04/21/2023 03:26 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: WESLEY PALMS
FACILITY NUMBER: 374600800

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2023
Section Cited

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87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:
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On 03/26/2023, a supervisor provided informal remedial training to S1, S2, S3, and S4. Then on 03/29/2023, a nurse from licensee’s contracted pharmacy led a training class on medication administration practices/procedures for S1, S2, S3, S4, and all other staff involved in medication pass duties. Licensee agreed to E-mail LPA a copy of the sign-in sheet for the training led by the pharmacy, by the POC date.
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Based on records and interviews, the licensee did not assist 1 of 317 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: WESLEY PALMS
FACILITY NUMBER: 374600800
VISIT DATE: 04/21/2023
NARRATIVE
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[CONTINUED FROM LIC 809]

Staff interviews, corroborated by records, revealed: R1’s antibiotic was prescribed twice per day, for ten (10) days, starting on 03/15/2023; as such, the pharmacy dispensed twenty (20) pills to licensee. By 03/25/2023, licensee identified there were two (2) excess doses remaining in inventory, compared to what staff logged/initialed as given to R1 per the facility’s Medication Administration Record (MAR). Licensee’s internal investigation concluded R1 missed two (2) prescribed doses of their antibiotic medication, during a period of ten (10) days, and that the culpable staff was some combination of Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), and/or Staff #4 (S4).

Per manager interviews: On 03/26/2023, a supervisor provided informal remedial training to S1, S2, S3, and S4. Then on 03/29/2023, a nurse from licensee’s contracted pharmacy led a training class on medication administration practices/procedures for S1, S2, S3, S4, and all other staff involved in medication pass duties.

One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Galicia, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC809 (FAS) - (06/04)
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