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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803921
Report Date: 07/19/2022
Date Signed: 07/29/2022 03:01:24 PM


Document Has Been Signed on 07/29/2022 03:01 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, THEFACILITY NUMBER:
486803921
ADMINISTRATOR:KINDRED, NICHOLEFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 592-1157
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: 96DATE:
07/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Grace SandovalTIME COMPLETED:
03:33 PM
NARRATIVE
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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced at The Lodge at Glen Cove for the purpose of following-up on an incident report that was forwarded to the Regional Office (RO). LPA was screened upon entrance and met Administrator, Grace Sandoval.

During today's visit LPA is following up on a self reported incident report received at CCL on 3/11/2022 involving residents (R1), (R2) and staff (S1) and a report of a medication error. The error occurred on 03/10/2022 while previous Care Coordinator (S1) was dispensing medication at 8:40 am and accidentally provided the wrong medication to R1. S1 provided the wrong medication for R1, when they gave them medication that belong to R2, both residents with the same first name. Medication error was reported to Residents Primary Care Provider, Kaiser Medical advise line, and residents family. Facility spoke with Kaiser RN along with Poison Control, who concluded that the medications given to R1 were similar and in line with the medications R1 currently takes and they did not deem it necessary that R1 be seen in person by a physician. Facility created resident photo cards to accompany labeled medication cups. Staff training and the use of the medication cart.

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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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 07/29/2022 03:01 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: 07/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2022
Section Cited

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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:
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Based on record review, and interview with Administrator the facility failed to ensure R1's medication was given as prescribed by doctor when S1 accidentaly gave R1 medication for a resident with the same name (R2) which poses an immediate health and safety risk to resident 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
LIC809 (FAS) - (06/04)
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