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25 | On 9/20/2024 Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez, conducted an unannounced Annual Continuation inspection from 9/13/2024. LPAs met with Executive Director (ED) Tina Bagheri Tayabeh and stated the purpose of today's visit.
During today's visit, LPAs reviewed 10 resident files and 5 at random resident centrally stored medication files and resident medications.
During inspection on 9/13/2024, in resident room #1, LPAs observed 3 over-the-counter medications and acetone alcohol in the mirror cabinet in the resident room which was not locked and accessible to the resident R1. Staff S1 stated R1 was on the facility medication management program and facility staff administered medications to R1. Based on review of R1's LIC 602A Physician's Report dated 2/22/2024, R1 is diagnosed with Dementia. During visit, facility staff removed the items and placed them in a locked cabinet in the resident's room.
During inspection on 9/13/2024, in resident room #2, LPAs observed 1 bottle of 19 oz Lysol disinfectant spray and 1 bottle of 91% isopropyl alcohol located on top of the bathroom sink which was not locked and accessible to resident R2. Based on review of R1's LIC 602A Physician's Report dated 9/3/2024, R1 is diagnosed with Dementia. During visit, staff S1 removed the item and placed them in a locked cabinet.
During inspection on 9/13/2024, in resident room #1, LPAs observed 2 multi-purpose scissors located in the bathroom and in the sitting area in the bedroom. Based on review of R1's LIC 602A Physician's Report dated 2/22/2024, R1 is diagnosed with Dementia. During visit, staff S1 removed the 2 scissors and placed them in a locked cabinet in the resident's room.
Continuation on LIC 809-C, Page 1 of 3. |
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During inspection on 9/13/2024, in resident room #3, LPAs observed 1 bottle of Clorox Disinfecting spray, 1 bottle of disinfection bleach, 1 bottle of Lysol Disinfecting spray and 1 bottle of Tide laundry detergent. Staff S1 stated R3 was on the facility medication management program and facility staff administered medications to R3. Based on review of R3's LIC 602A dated 9/28/2023, R3 is not able to administer own prescription medications, R3 is not able to store own medication, R3 is occasionally confused or forgetful. During visit, staff S1 removed 4 bottles of disinfectants and cleaning solutions from R3's room and placed them in a locked cabinet.
During inspection on 9/13/2024, in resident room #4, LPAs observed 1 prescribed medication bottle which was filled in May 2024 in the mirror cabinet over the bathroom sink in the bathroom. LPAs observed resident R4 was present in the room during the time of inspection. Staff S1 stated R4 was on the facility medication management program and facility staff administered medications to R4. Based on review of R4's LIC 602A dated 3/18/2024, R4 is not able to administer own prescription medications and is not able to store own medication. During visit, staff S1 removed the prescription medication and personally took the medication into the locked medication room.
During today's inspection, LPA Marcela reviewed 5 resident medications and record of centrally stored prescription medications. LPA Marcela observed 2 out of 5 record of centrally stored prescription medications had either the wrong start date written on the record and medications were administered to the resident. LPA Marcela reviewed resident R1's medication, 1 medications had different start dates recorded on Centrally Stored Medication Log and resident's medication bubble pack. Medication N had start date on medication bubble pack was recorded as 8/25/2024 and the start date on the centrally stored medication log was recorded as 8/22/2024. LPA Marcela reviewed resident R2's medication, 1 medication had different start dates recorded on Centrally Stored Medication Log and resident's medication bubble pack. Medication G had start date on medication bubble pack was recorded on 9/9/2024 and the start date on the centrally stored medication log was recorded as 9/10/2024.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
09/21/2024
Section Cited
CCR
87705(f)(2)
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7 | 87705(f)(2)Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement was not met as evidenced by:
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7 | Executive Director stated to submit a written plan of action understanding regulation and notifing residents and/or responsible party and staff in-service training by POC due date. Executive Director agreed and understood. |
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14 | Based on observation and record review, LPAs observed OTC medication, alcohol, and toxic substances in resident bedrooms who are diagnosed with dementia and accessible to residents which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care. | 8
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14 | During visit, staff S1 removed the items and placed them in a locked cabinet. |
Type A
09/21/2024
Section Cited
CCR87705(f)(1)
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7 | 87705(f)The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement was not met as evidenced by: | 1
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7 | Executive Director stated to submit a written plan of action understanding regulation and in-service training by POC due date. Executive Director agreed and understood.
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14 | Based on observation and record review, LPAs observed 2 scissors in the bathroom and resident room which was accessible to resident with dementia which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care. | 8
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14 | During visit, staff S1 removed the items and placed them in a locked cabinet. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
09/21/2024
Section Cited
CCR
87309(a)
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7 | 87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by: | 1
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7 | Executive Director stated to submit a written plan of action understanding regulation and notify resident and/or responsble party and provide in-serice training by POC due date. Executive Director agreed and understood. |
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14 | Based on observation and record review, LPAs observed 4 bottles of disinfectants and cleaning solutions in resident R3's bathroom underneath the bathroom sink which was not locked and accessible to the resident which poses/posed an immediate Health, Safety or Personal Rights risk to persons in care. | 8
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14 | During visit, staff S1 removed the 4 bottles and placed them in a locked cabinet.
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Type A
09/21/2024
Section Cited
CCR87465(h)(2)
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7 | 87465(h)(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. This requirement was not met as evidenced by: | 1
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7 | Executive Director stated to submit a written plan of action understanding regulation and provide in-service training to staff by POC due date. Executive Director agreed and understood. |
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14 | Based on observation and record review, LPAs observed medications in 1 residents rooms which were accessible and unlocked to the residents unable to administer own medication which poses/posed an immediate Health, Safety or Personal Rights risk to persons in care. | 8
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14 | During visit, staff S1 removed the medication from the residents room and placed in the medication rooom. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
09/27/2024
Section Cited
CCR
87465(h)(6)
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7 | 87465 (h)(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...This requirement is not med as evidenced by:
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7 | Executive Director stated to submit a written plan of action understanding regulation and schedule in-service training for medication technicians to complete the records of centrally stored prescription medications for residents by POC due date. Executive Director agreed and understood. |
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14 | Based on observation and record review, LPA observed 2 out of 5 Centrally Stored Medication Records was not completed accurately which poses/posed a potential Health, Safety or Personal Rights risk to persons in care. | 8
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