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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500310664
Report Date: 02/07/2024
Date Signed: 02/16/2024 01:35:15 PM


Document Has Been Signed on 02/16/2024 01:35 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/16/2024 01:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

NARRATIVE
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This report is being amended to complete the visit for 02/07/24 to update the original POC and correct verbiage.

Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Case Management on 02/07/2024. The case management visit pertains to an incident report received on 12/04/2024.

During the visit, the LPA met with Administrator Margaret Homa and collected documents pertinent to the incident report. LPA Campbell obtained R1's MAR for November and December, their 602 and their prescriptions for review. R1’s ID sheet was also utilized to confirm notification procedures.

Per the administrator, the medication error that occurred on 12/01/23 was due to med tech error. LPA Campbell observed that the MAR reported that R1 received medication on 12/01/23. Per S2, the details of the med error were entered in the staff notes. No signature/initial key was provided on the back of the MAR to clarify the full name of which Med Tech passed out medication. The Med Tech who passed out the wrong medication for R1 could not be interviewed because they were out of the country.

Based on LPAs observations and interviews the preponderance of evidence standards has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. This poses an immediate Health and Safety risk to residents in care. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

Exit interview held. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. A copy of todays’ report provided.
SUPERVISOR'S NAME: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
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 02/16/2024 01:36 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/16/2024 01:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: ST. THOMAS RETIREMENT CENTER
FACILITY NUMBER: 500310664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2024
Section Cited
CCR
87465(a)(5)(A)

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87465 Incidental Medical and Dental Care. (a) Staff designated by... licensee may assist ... with self-administered medications. .. limited to the following: (A) Medications usually prescribed for self-administration ... authorized by the person's physician. This requirement was not met as evidenced by:
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The administrator will complete a memorandum of understanding and include a plan to cover absent Med-Techs for emergencies by the POC date on 02/22/2024 and email it to LPA Campbell at renee.campbell@dss.ca.gov
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Based on observation and interviews and record review, the facility provided the wrong medication to the wrong resident (R1) which poses 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: Lisa RiosTELEPHONE: (916) 969-9685
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: (916) 206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024
LIC809 (FAS) - (06/04)
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