Community Care Licensing

Document Has Been Signed on 06/06/2023 02:03 PM - It Cannot Be Edited

FACILITY NAME:	HEARTS AT MILLWOOD ASSISTED LIVING		FACILITY NUMBER:	415601085
ADMINISTRATOR:	ERMITANO, ELAINE B.		FACILITY TYPE:	740
ADDRESS:	416 MILLWOOD DR		TELEPHONE:	(650) 777-8166
CITY:	MILLBRAE	STATE: CA	ZIP CODE:	94030
CAPACITY: 6		CENSUS: 5	DATE:	06/06/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Eli Ermitano		TIME COMPLETED:	02:15 PM

SUPERVISORS NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023

Link to Parent Document Below:

FACILITY NAME: HEARTS AT MILLWOOD ASSISTED LIVING	FACILITY NUMBER: 415601085
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2023

Type B

Section Cited

CCR

87633(b)

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of client records, the licensee did not comply with the section cited above, as client #4 was on hospice from 3/7/23 until 6/5/23 and hospice care plan was not maintained. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	Hospice care plan for client #4 to be submitted to CCLD by DUE DATE, and will include use of half bed rails.

Type B

Section Cited

CCR

87705(c)(5)

Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of client records, the licensee did not comply with the section cited above, as client #1, who is diagnosed with dementia, has MD report dated 11/21 and appraisal dated 8/20. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	MD report and appraisal for client 1 will be updated and copies will be sent to CCLD BY DUE DATE

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023

Link to Parent Document Below:

FACILITY NAME: HEARTS AT MILLWOOD ASSISTED LIVING	FACILITY NUMBER: 415601085
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2023

Type B

Section Cited

CCR

87465(h)(6)

(h)(6) A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of clients' medications, the licensee did not comply with the section cited above, as medications are not logged on Centrally Stored Medications Records until medications are started or bottles are opened, instead of upon receipt. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	All clients' medications shall be recorded on Centrally Stored Medications Records upon receipt, to document all clients' medications, not just those that have been started/opened. Copies of completed CSMRs for 5 clients to be sent to CCLD BY DUE DATE.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 06/06/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/06/2023