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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603952
Report Date: 08/29/2022
Date Signed: 08/29/2022 03:16:06 PM

Document Has Been Signed on 08/29/2022 03:16 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:PROSPECT MANORFACILITY NUMBER:
197603952
ADMINISTRATOR:LYDIA PABIONFACILITY TYPE:
740
ADDRESS:800 PROSPECT AVETELEPHONE:
(626) 799-1141
CITY:SOUTH PASADENASTATE: CAZIP CODE:
91030
CAPACITY: 99CENSUS: 54DATE:
08/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lydia Pabion - Administrator TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted a case management visit during a complaint investigation visit conducted on 8/29/22. LPA Flores met with Lydia Pabion Administrator and explained the reason for the visit.

On 8/29/22 LPA Flores reviewed medication sheets for Resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6) during the review LPA Flores observed medication sheets were not updated for morning dose provided to each resident. Per facility's nurse (LVN) medication is provide to residents either during breakfast at the dining room, or residents walk to the medication room to request, or provided in the residents room and does not note after providing the dose to each resident at the time each is provided. LPA Flores observed medication bubble packs are out of cycle and was unable to identify if medication was provided that morning. LPA Flores observed medication bubble pack for Resident #7 was crossed out with black marker and rename with red marker with R2's name. Per administrator pharmacy made a mistake in the order and place the order for R7 instead of R2. LPA Flores observed R2 and R7 had two sets of bubble packs for the same medication for each dose. Last medication training provided on 8/21/22,

Deficiencies were given based on observations per Title 22 Division 6 Chapter 8 and noted on LIC809D.

Exit interview was conducted with Lydia Pabion - Administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2022
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 2
Document Has Been Signed on 08/29/2022 03:16 PM - It Cannot Be Edited


Created By: Mary G Flores On 08/29/2022 at 02:05 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PROSPECT MANOR
FACILITY NUMBER: 197603952

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2022
Section Cited
CCR
87465(e)

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87465 Incidental Medical and Dental Record: (e) For every prescription and nonprescription... there shall be a signed, ..., and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidence by:
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Administrator will request medication with corrected label from pharmacy for medication for R2 and submit picture of the medication by 9/5/22.
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Based on observation licensee did not ensure medication for R2 had the proper pharmacy label which poses a potential risk to the health, personal rights, or safety of the residents in care.
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Type B
09/05/2022
Section Cited
CCR87465(a)(6)

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87465 Incidental Medical and Dental Care: (a) A plan... shall be developed by each facility... (6) ... a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidence by:
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Administrator will ensure medication provided to the residents is on cycle and record properly by staff on medication sheet by certifying on LIC 9098 by POC due date 9/5/22.
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Based on observation licensee did not ensure Med techs are recording medication dosages provide to the residents at each dose for R1,R2,R3,R4,R5,R6 review which poses a potential risk to the health, personal rights, or safety of the residents 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:Stefanie Coronel
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2022


LIC809 (FAS) - (06/04)
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