486803921-6-5-2023-21-AS-ACAA-CSJ3HF-20230605181549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 06/05/2023
Date Signed: 06/05/2023 06:15:59 PM

Document Has Been Signed on 06/05/2023 06:15 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	LODGE AT GLEN COVE, THE		FACILITY NUMBER:	486803921
ADMINISTRATOR:	SANDOVAL, GRACE		FACILITY TYPE:	740
ADDRESS:	140 GLEN COVE MARINA ROAD		TELEPHONE:	(707) 592-1157
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	155	CENSUS: 109	DATE:	06/05/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	03:10 PM
MET WITH:	Grace Sandoval, Administrator		TIME COMPLETED:	05:41 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) A. Canela conducted an unannounced Case Management- Incident visit and met with Administrator, Grace Sandoval. LPA went over several incident reports that were submitted by the facility as required. LPA had previously went over several incident reports for resident R1 who had falls on 4/12, 4/13, and 4/14 and resident and their family had refused medical attention. Facility placed R1 on 72 hour checks after R1 was found on the floor but did not complain of any pain. On 5/21/23 R1 was found on the floor, did not complain of pain and refused medical attention. On 5/22/23 facility reported they found R1 on the floor again and their left ankle was swollen and R1 complained of hip pain. 911 was called by facility and R1 was sent to the hospital and diagnosed with a left ankle fracture and given a soft cast. R1 returned the same day. It was also reported by facility that on 4/29/2023 at 9:04pm, the facility received a call from R1's daughter to report R1 was outside. Staff went out and R1 was found at the end of the street sitting down on the floor. A man that was walking by saw R1 on the floor and helped to call R1's daughter, who then notified facility. No visible injuries were noted, but facility was unaware R1 had left the premises. On 5/7/2023 it was also reported staff went to R1's room at 8:00am to bring them to the dining area for breakfast and staff could not locate R1. Staff began searching and after 5 minutes, saw R1 outside walking searching for their sister. Resident became verbally abusive but agreed to return to the facility. Facility explained, resident is not diagnosed with Dementia on their LIC602 Physicians report and went out the back door. LPA explained the facility is responsible for knowing if a resident has left the premises and should be exiting the main entrance. LPA also requested facility to get resident assessed and submit a new Physicians report to Community Care Licensing. Continue report see LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LODGE AT GLEN COVE, THE	FACILITY NUMBER: 486803921
	VISIT DATE: 06/05/2023

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LPA A. Canela also went over an incident report that was self reported and submitted by the facility back on October 10/16/2022 regarding resident R2 and a medication error, in which back then facility explained to LPA they had conducted medication training. On 10/16/22 staff S3, reported R2 had 2 Fentanyl patches on, when they were going to apply one. The order is to apply one Fentanyl patch every 72 hours. Patches were removed and a new patch was applied. Facility notified family, Hospice nurse and immediately conducted medication training for staff.

A Civil penalty for $250. 00 was assessed today for repeated citation 87465(a)(5)

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Administrator and appeal rights were given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/05/2023 06:15 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LODGE AT GLEN COVE, THE	FACILITY NUMBER: 486803921
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/06/2023 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self administered medications when needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator had already conducted medication training and provided proof to LPA to clear citation
	8 9 10 11 12 13 14	Based on self reported incident and interview with Administrator the facility failed to ensure R2's medication was given as prescribed by doctor. Staff found R2 had 2 Fentanyl patches at one time, staff failed to remove one of the patches before applying another one, which poses an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14	repeated CITATION $250.00
Type A 06/06/2023 Section Cited CCR87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based on review of incident report and interview with Administrator, this requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Facility to ensure R1 plan of care is updated to reflect an AWOL alert POC date 6/6/2023. Caregiver staff to be trained in AWOL protocols/procedures by 6/15/2023-
	8 9 10 11 12 13 14	Resident R1 left the facility on two occasions, one being at 9pm at night, without the facility knowing or R1 signing out. This is an immediate risk to the health and safety of residents in care. This requirement is not met	8 9 10 11 12 13 14	in addition facility to obtain a new medical assessment LIC602 for resident R1 and send in to CCL LPA A Canela when received .

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2023

LIC809 (FAS) - (06/04)

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