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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801936
Report Date: 08/10/2023
Date Signed: 08/10/2023 11:52:37 AM

Document Has Been Signed on 08/10/2023 11:52 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BAUER RESIDENTIAL SANTA MARIA 4FACILITY NUMBER:
425801936
ADMINISTRATOR:MOSHE DAVISFACILITY TYPE:
735
ADDRESS:572 INGER DRIVETELEPHONE:
(714) 306-4068
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 6CENSUS: 5DATE:
08/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jaime Staine, ManagerTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jenny Olson conducted a Case Management - Incident visit to issue deficiencies on medication errors the facility has experienced. LPA met with Jaime Staine and explained the purpose of the visit.

On 08/03/2023, CCL received an incident report stating on 07/31/2023 Staff had failed to dispense Resident 1 (R1) Olanzapine 10mg tablet 3 times a day. Staff were unaware the medication changed from a PRN to routine medication. Staff spoke with R1’s doctor who changed the medication on 4/29/23. Staff found three months of Olanzapine 10mg un-dispensed in sealed medication bubble packs.

On 8/10/23, Staff stated that yesterday they were informed Resident 2 (R2) had their PRN Loratadine 10mg changed to routine on 6/13/23 but hasn't been receiving it routinely, only as a PRN. Staff stated they will submit an incident report later today.

LPA advised facility to get the MAR from the pharmacy and not make it themselves to prevent this from happening again.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

An exit interview was conducted, a copy of the report, and appeal rights were issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2023
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 08/10/2023 11:52 AM - It Cannot Be Edited


Created By: Jeannette Olson On 08/10/2023 at 09:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BAUER RESIDENTIAL SANTA MARIA 4
FACILITY NUMBER: 425801936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2023
Section Cited
CCR
80075(b)(5)(B)

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80075(b)(5)(B) Health Related Services. Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
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Administrator agreed to schedule medication training for all staff and send the date to CCL by 8/11/23 and send proof of all staff training by 8/17/23.
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Based on records review and interview, the licensee did not comply with the section cited above when staff did not follow physician’s orders for medications, which posed 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:Kelly Burley
LICENSING EVALUATOR NAME:Jeannette Olson
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023


LIC809 (FAS) - (06/04)
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