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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 09/02/2021
Date Signed: 09/02/2021 11:30:52 AM

Document Has Been Signed on 09/02/2021 11:30 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:AA BEST CARE HOMESFACILITY NUMBER:
496801684
ADMINISTRATOR:AQUINO, NICANORFACILITY TYPE:
740
ADDRESS:857 HEARN AVE.TELEPHONE:
(707) 546-8413
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 40CENSUS: 28DATE:
09/02/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Nick Aquino (Licensee)TIME COMPLETED:
11:46 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management Inspection and met with Licensee, Nick Aquino. LPA conducted risk assessment call with Licensee prior to visit. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet. However, the staff did not ask any of the screening questions to LPA. Licensee and LPA discussed the importance of screen visitors.

LPA is following up regarding five incident reports received involving resident (R1) had trouble breathing. On 6/2/21 R1 complained about difficulty breathing and was transported to Santa Rosa Memorial Hospital. R1 and was diagnosed with Dyspnea and was prescribed new medication Prednisone 10mg for 4 days. R1 is a heavy smoker and was instructed to limit cigarette intake and responsible party agreed with Administrator to reduce the amount of money from $60 to $30 for cigarettes. On 6/7/21 R1 was having trouble breathing and was transported to Santa Rosa Memorial Hospital. Administrator agreed with responsible party that no more money was going to be provided to R1 until their smoking habit changes. On 8/1/21 R1 had trouble breathing and was transported to the hospital were received a diagnosis of Emphysema. R1 smokes an average of 3 packs of cigarette per day and responsible party provided Lozenges to help with smoking issue. R1 on 8/5/21 had a hard time breathing and received an increase of medication Prednisone 50mg tablet and azithromycin 250 mg tablets for Chronic Obstructive Pulmonary Disease. Once again on 8/11/21 R1 was transported to the Hospital due to difficulty breathing and no new or adjusted medication order was prescribed. According with Licensee, Facility has developed a plan to help R1 to quit smoking.

LPA also discussed with Licensee the importance of update R1's care plan to include recent diagnosis and make sure that the facility can provide the care and supervision that meets resident needs. As of today, R1 has not experienced any incidents. Licensee mentioned to LPA Facility is working with resident's responsible party and case worker to help R1 to quit smoking.

Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: AA BEST CARE HOMES
FACILITY NUMBER: 496801684
VISIT DATE: 09/02/2021
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Continued from LIC809...

Discharge documents dated 6/4/21 indicated that R1 has medical issues as asthma with acute exacerbation, COPD exacerbation, schizophrenia and tardive dyskinesia. LPA also reviewed R1’s care plan dated 5/5/20 encouraged R1 to stop smoking.

At approximate 10:30am LPA/Licensee/staff conducted a spot check of R1's medication and observed multiple medication errors. Facility provided R1's Medication Assistance Records (MARs) for the month of August 2021 revealed R1's medications were not entered for the month of September 2021 by staff. Also, Centrally Stored Medication Records printed at the time of visit indicated medication records has not been updated in the system by staff for 7 out 7 prescribed medication (Gabapentin 800mg, Atorvastatin 10mg, Haloperidol 5mg, Ziprasidone 80mg, Omeprazole 10mg, Vitamin D3 and Morphine Sulfate 15mg). LPA/Licensee contacted staff (S1) and S1 assures that R1 was assisted with the administration of medications as prescribed per physician’s order. However, S1 could not provide any proof or explanation about the missing filled date and start date on R1’s bubble packs medication and in the Centrally Stored Medication Records.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Civil Penalties are also being assessed in the amount of $250 due to a 2nd repeat citation issued for the same sections in less than 12 months.


*****Total Civil Penalties issued today in the amount of $250.00
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/02/2021 11:30 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 09/02/2021 at 10:47 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: AA BEST CARE HOMES
FACILITY NUMBER: 496801684

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2021
Section Cited
CCR
87465(h)(6)(D)

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87465 (h)(6)(D) Incidental Medical & Dental Care.The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least 1 yr & includes: (D) The date filled. This requirement has not been met as evidence by:
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Licensee agrees to conduct a medication audit for all residents, retrain staff on medication management from an outside vendor & will write a plan to ensure resident medications are logged into the Centrally Stored Medication Records daily. Licensee to submit the updated plan to CCL by POC due date 9/3/21. Civil Penalties issued today in the amount of $250.00
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Based on observation, records review & interviews with staff, Licensee did not ensure proper management of medication. LPA/Licensee conducted a medication audit & found multiple medication errors for R1's meds which poses an immediate health & safety risk to resident in care.
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Type A
09/03/2021
Section Cited
CCR80072(a)(2)

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80072 Personal Rights (a)... residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement has not been met as evidence by:
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Licensee/Administrator will ensure Personal Rights of residents are maintained. Licensee agrees to submit proof of training for all staff to conduct screening of all visitors for Covid19 symptoms to CCL by close of business 9/3/2021.
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Based on interviews and record review, Licensee did not ensure the personal rights of persons in care to safe & health accomodations. Staff did not screen LPA for Covid19 symptoms to prevent entry of possible infected persons and to be in compliance with CCL guidelines which poses/posed an immediate health, safety or personal rights 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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2021


LIC809 (FAS) - (06/04)
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