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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601592
Report Date: 12/21/2021
Date Signed: 12/21/2021 06:52:31 PM

Document Has Been Signed on 12/21/2021 06:52 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TRUDEZ HOME CAREFACILITY NUMBER:
197601592
ADMINISTRATOR:LOPEZ, VIRGILIOFACILITY TYPE:
740
ADDRESS:23844 VIA JACARATELEPHONE:
(661) 259-7019
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY: 6CENSUS: 5DATE:
12/21/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Consuelo Connie CiprianoTIME COMPLETED:
07:00 PM
NARRATIVE
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An unannounced Plan of Correction (POC) in conjunction with a Subsequent Complaint (Complaint Control # 31-AS-20210604142033) visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan the purpose of this visit is to follow up on the Plan of Corrections (POCs) that were issued on 6/7/2021

On 6/9/2021, 11/27/2021, 12/9/2021 LPA Avetisyan sent an email to virgil.lopez@yahoo.com notifying the administrator that plan of corrections are still outstanding. A discussion was made via email however as of today's visit the licensee/administrator have failed to submit plan of corrections to the Department.

Upon arrival to the facility LPA met with staff Consuelo Connie Cipriano and Manuel Cipriano. Ms. Cipriano contacted the licensee Waldi Lopez. Ms. Lopez informed the staff that administrator Virgilio Lopez is currently unavailable. Neither licensee or administrator were available to come to the facility. Per Staff the licensee has asked her to sign for the report.

Approximately 2:30 pm LPA conducted a tour of the facility with Ms. Cipriano. While conducting tour LPA observed the following.
  • RM 1: Currently being occupied by 2 residents. Resident 1 (R1) is currently utilizing a full rail and Resident # 2 (R2) is utilizing a half rail At 2:32 pm when asked staff stated that neither resident are currently receiving hospice services. Staff also informed the LPA that they have to reposition both residents every 2 hours because they are unable to do so.
  • RM # 2 is currently being used as a staff room.
  • RM # 3 is currently occupied by 1 resident (R4)
  • RM#4 is currently being occupied by 1 hospice resident (R3) who is utilizing a full rail.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197601592
VISIT DATE: 12/21/2021
NARRATIVE
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LPA asked Ms. Cipriano where the 5th resident in residing. Staff walked the LPA to the living room and pointed toward a resident watching TV. LPA asked which room the resident is staying in. At 2:39 pm staff stated that the resident does not stay at the facility. Resident 5 (R5) is dropped off by family 7:00 am and picked up at 5:00 pm Tuesday through Saturday.

From 2:45 pm LPA conducted review of the residents files and observed them to be incomplete. LPA also observed that licensee failed to complete the plan of corrections as cited during the 6/7/2021 visits.

On 6/7/2021 the licensee was cited the following deficiencies.

87608 (a)(5)(B) : Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. During that visit the licensee was utilizing full bed rails for a resident who was on hospice however did not have the hospice care that documented the need for the full rails. Licensee was to submit copy of the hospice care plan as POC. During todays visit LPA observed 2 residents who are utilizing full rails (R1 and R4). R1 is not on hospice. R4 is on hospice however the licensee does not have the care plan that would indicate the need for the full rail.

87608 (a)(3) Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed. This requirement is not met as evidenced by: During that 6/7/2021 visit the licensee was utilizing postural support for 2 residents. Licensee was to obtain orders for the postural support and submit it to the LPA as POC. During today's visit LPA observed that R2 is currently utilizing postural supports and the licensee does not have any order from the physician.

87705 (c)(5)(A) Licensees who accept & retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment, & a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. During the 6/7/2021 licensee did not have current medical assessment for 4 residents who were diagnosed with Dementia. Licensee was to obtain current Medical Assessment for the residents, complete re-assessments and submit copies as POC. During todays visit LPA observed that the licensee does not have a current physicians report for R1. and physicians report for R2 is incomplete and inaccurate.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 12/21/2021 06:52 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 12/21/2021 at 04:25 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited
CCR
87608(a)(5)(B)

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(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
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Licensee/Administrator will review the regulation., contact the hospice agency and obtained a current hospice care plan which will indicate the need for the full rail. Licensee will ensure to utilize full rail if order is obtained and not 2 half rails. Copy of the hospice care plans will be submitted as POC.
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Based on observations the licensee did not comply with the section cited by utilizing full bed rails for 2 out of 5 residents (R1 and R4). Licensee does not have the hospice care plan to indicate the need for the full rails for R4 and R1 is currently not on hospice. which poses an immediate health, safety & personal rights risk to R1 and R4.
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Licensee/administrator will notify the Department in writing how they intend to clear the deficiency for R1.

This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.
Type A
12/23/2021
Section Cited
CCR87608(a)(3)

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Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed. This requirement is not met as evidenced by:
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Licensee/administrator will contact physicians and obtain orders for the postural support bed rail for R2 and submit copy as POC.
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Based on Records review, observations the licensee did not comply with the section cited by not obtaining an order for postural support for R2 which poses a potential health, safety or personal rights risk to persons in care.
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This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.
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:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 12/21/2021 06:52 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 12/21/2021 at 04:45 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2021
Section Cited
CCR
87705(c)(5)(A)

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(c) Licensees who accept & retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment, & a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
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Licensee/Administrator will obtain updated and complete medical assessments for R1 and R2 and complete re-appraisals. Copies of the documents will need to be submitted as POC.
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Based on LPA record review, the licensee did not comply with the section cited by not obtaining an complete Annual Medical assessment and not completing annual re-appraisals for 2 out of 5 residents diagnosed with dementia. This poses a potential health and safety risk to the residents in care.
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This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.
Type A
12/23/2021
Section Cited
CCR87465(a)(6)(D)

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(D) Assistance with self-administration does not include forcing a resident to take medications, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.
This requirement is not met as evidenced by:
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Licensee/administrator will contact R1 and R2's physicians and obtain an order to crush medications. Copy of the order will be submitted as POC.
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Based on interview with staff, the licensee did not comply with the section cited above by crushing and camouflaging medications with food without a doctors order for 2 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.
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This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.
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:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197601592
VISIT DATE: 12/21/2021
NARRATIVE
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At 3:23 pm LPA contacted the office of R1's PCP who will review the information and provide an update to the LPA. R1 was one of the 4 residents identified during the 6/7/2021 visit.

87465(a)(6)(D): Assistance with self-administration does not include forcing a resident to take medications, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. Licensee was to contact the residents physician and obtain orders to crush medications. During todays visit at 4:50 pm staff informed the LPA that she is currently crushing medications for R1 and R2 who are on a puree diet. Resident files did not document the order from the physician to crush the medications.
87465 (b)(c)(d) Licensee is required to have PRN authorization letter on file signed by a physician to determine whether or not the residents can communicate the need and/or symptoms clearly for the as needed (PRN) medication. During the visit licensee did not have PRN authorization letter for 4 out of 4 residents. During this visit while conducting review of the resident files LPA observed that the licensee/administrator did not obtain PRN authorization letters for any of their residents.
87465 (C3)(D3) (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. During the 6/7/2021 visit and todays visit record reviews revealed that the licensee is not utilizing PRN administration logs for resident. Licensee was to submit copy of blank PRN administration log and a written statement that the log will be completed as necessary.
87202 (a) (2) FIRE CLEARANCE. All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance. The licensee was retaining two bedridden residents without proper fire clearance. During the visit the administrator was informed that because this was a zero tolerance violation civil penalties in the amount of $500 was issued and that civil penalty in the amount of $100 per day would continue to accrue until they submitted an LIC 200 and facility sketch. LPA made several attempts to obtain the information, emailed the administrator a blank LIC 200 however the plan of correction was not submitted. During todays visit while speaking with staff and reviewing records revealed that the licensee continues to retain 2 bedridden residents (R1 and R2) in addition both residents rely on staff to perform all activities of daily living for them For failure to submit plan of corrections a civil penalty of $100 per day is hereby assessed for the period of 6/8/2021 to 12/21/2021 totaling $19,800.00 . The $19,800.00 penalty assessed is a continuation of the civil penalty issued on 6/7/2021 in the amount of $500.00 because this is a zero tolerance violation.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 12/21/2021 06:52 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 12/21/2021 at 05:02 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited
CCR
87465(b)(c)(d)

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Licensee is required to have PRN authorization letter on file signed by a physician to determine whether or not the residents can communicate the need and/or symptoms clearly for the as needed (PRN) medication.

This requirement is not met as evidenced by:
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Licensee/Administrator will contact residents Physicians to obtain PRN authorization letters for all residents who they provide medication assistance to. Copies of the PRN authorization letters will need to be submitted as POC.
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Based on record review, the licensee did not comply with the section cited above by not obtaining PRN authorization letters for 5 out of 5 residents which poses a immediate health, safety or personal rights risk to persons in care
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This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.
Type A
12/23/2021
Section Cited
CCR87465(C3)(D3)

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(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
This requirement is not met as evidenced by:
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Administrator will create PRN administration log to be utilized at the facility. A copy of the log with a written statement indicating that PRN logs will be used as necessary for all residents will be submitted as POC.
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Based on record review, the licensee did not comply with the section cited above by not keeping PRN administration records when given to 3 out of 4 residents poses a potential health, safety or personal rights risk to persons in care.
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This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 visit.
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:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 12/21/2021 06:52 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 12/21/2021 at 05:10 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited
CCR
87466

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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the
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which posed an immediate health, safety or personal rights risk to persons in care.

Licensee/administrator will notify the department what steps will be taken to ensure that they are in compliance with the cited regulation at all time.
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licensee shall ensure that such changes are documented and brought to the attention of the resident's physician & the resident's RP if any. This requirement is not met as evidenced by: Based on interview with staff the licensee did not comply with the section cited by not notifying prior residents physician of a change in condition
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This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 initial 10 day complaint visit.
Type A
12/23/2021
Section Cited
CCR87465(a)(5)

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Incidental Medical and Dental Care Services. The licensee shall assist residents with self administered medications as needed/prescribed

This requirement is not met as evidenced by
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Licensee/Administrator and all staff will attend vendorized medication training. Training will need to be scheduled within 24 hours and completed within 14 days. Administrator will also contact a pharmacy and schedule a medication audit. Copy of the medication audit will need to be submitted as POC.
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Based on interview, record review and medication count, the licensee did not comply with the section cited by not assisting prior resident with self administration of medications as prescribed. which poses an immediate health, safety or personal rights risk to persons in care.
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This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 initial 10 day complaint visit.
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:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197601592
VISIT DATE: 12/21/2021
NARRATIVE
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On 6/7/2021 LPA conducted an initial 10 day complaint visit at which time the licensee was cited for the following deficiencies. Plan of Corrections were not submitted.

87466 Observations of Resident - Licensee/administrator was to notify the department in writing what steps would be taken to ensure that they are in compliance with the cited regulation

87465 (a)(5) Incidental Medical and Dental Care Services - Licensee/administrator and staff failed to provide proper medication assistance to residents. The licensee/administrator and all staff were to schedule and complete vendorized medication training and request a medication audit to be completed by a pharmacist. When asked staff confirmed not receiving medication training.
87465 (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 and includes: all the required information. The licensee/administrator/staff for not completing Centrally Stored Medication and Destruction record for prior resident. During todays visit LPA observed that the licensee does not have current/complete Centrally Stored Medication and Destruction record for all residents.

87465 (e) Incidental Medical and Dental Care: For every prescription ... for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Licensee/administrator did not have order from and a discontinue order signed by a physician for prior resident. Licensee/administrator was to contact the physician for the resident and obtain the needed prescriptions and discontinue orders. This Deficiency is cleared because the resident is no longer living at the facility.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 809-D).

Exit interview conducted, with staff and copy of report, citations, civil penalties and appeal rights emailed to info@trudezhomecare.com and virgil.lopez@yahoo.com
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 12/21/2021 06:52 PM - It Cannot Be Edited


Created By: Yelena Avetisyan On 12/21/2021 at 05:24 PM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRUDEZ HOME CARE
FACILITY NUMBER: 197601592

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2021
Section Cited
CCR
87465(6)

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(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 and includes: all the required information.

This requirement is not met as evidenced by:
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Licensee/administrator will complete form for all residents after the medication audit. Copy of the completed forms along with a written statement that the forms will be completed and updated regularly will need to be submitted as POC.
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based on record review the licensee/administrator did not comply with the section cited by not completing Centrally Stored Medication and Destruction record for 5 out of 5 residents which poses a potential health, safety and personal rights risk to persons in care.
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This deficiency is being recited because the licensee/administrator failed to submit the POC as discussed during the 6/7/2021 initial 10 day complaint visit.

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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:Eva Miller
LICENSING EVALUATOR NAME:Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


LIC809 (FAS) - (06/04)
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