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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850025
Report Date: 06/15/2023
Date Signed: 06/15/2023 11:01:54 AM


Document Has Been Signed on 06/15/2023 11:01 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:SANTA MARIA TERRACEFACILITY NUMBER:
425850025
ADMINISTRATOR:ENRIQUEZ, SANJUANAFACILITY TYPE:
740
ADDRESS:1405 E MAIN STTELEPHONE:
(805) 925-8713
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:140CENSUS: 94DATE:
06/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Joanna Enriquez, AdministratorTIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20230224144738). The purpose of the visit is to issue a citation for deficiencies observed during the complaint investigation.

During the complaint investigation, the following deficiency was observed: Facility Centrally Stored Medication and Destruction Record (CSMDR) records for Resident #1 (R1) were missing the quantity for Vitamin C, Hydrochlorothiazide. The other medication had the total amount listed on the bottle, not actual amount.

CCL received an incident report on 3/9/23 stating Resident 2 (R2) noticed residents Alendronate needed a refill. This is a weekly dosed medication with the refill date to be 3/1/23 but all weekly doses were given. The first dose was given on 3/3/23 and 3 more doses given daily, leaving resident without weekly dose for the month of March.

Citations issued, exit interview, copy of report, appeal rights were printed and emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
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 06/15/2023 11:01 AM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: SANTA MARIA TERRACE
FACILITY NUMBER: 425850025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2023
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...(4) The licensee shall assist residents with self administered medications as needed.
This requirement was not met as evidenced by:
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Facility immediately took the medtech responsible off medication passes and retrained medtechs on the 7 steps of issuing mediation. Plan of correction complete.
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Based on record review, the licensee did not comply with the section cited above when the facility did not follow doctors orders and properly assist resident with medication, which poses an immediate health and safety risk to persons in care.
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Type B
06/22/2023
Section Cited
CCR87465(h)(6)

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87465(h)(6) Incidental Medical and Dental Care (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (C) The drug name, strength and quantity. This requirment was met as evidenced by:
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Administrator agreed to train medtech's on the proper way to fill out the centrally stored medication log and submit training to CCL with name, date, and topic covered by 6/22/23.
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Based on record review, the licensee did not comply with the section cited above when the facility did not assure the centrally stored medications had the correct quantity, which poses a potential health and safety 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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
LIC809 (FAS) - (06/04)
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