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25 | At approximately 11:25AM, Licensing Program Analysts (LPAs) Felias and Frank arrived unannounced to continue a 1-Year Required Visit and met with Licensee/Administrator, Pilar De Olave. Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 5 residents, where 4 can be non-ambulatory. Facility has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 3 Residents in care and 1 staff member on-site.
LPAs reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPAs reviewed medications. During review, LPAs observed that 2 of 3 residents' most recent medications were not documented on the log as required. Review of facility's log indicated that facility understands how to document medications appropriately (technical assistance issued, LIC9102, regulation 87465(h)(6)).
Facility's last emergency/disaster drill was conducted November 2024. Administrator Certificate for Pilar de Olave (7008943740) was pending with renewal application received of 12/02/2024. Review of staff files did not show that annual training had been conducted for 2024. LPAs spoke with Staff Member 1 (S1) who stated that they have received their 20 hours of annual training as required. Discussion with Licensee/Administrator stated that they have conducted training but did not document it. LPAs discussed with Licensee about the importance of documenting training as required (technical violation issued, LIC9102, 1569.625(b)(2)).
The following deficiencies that were cited during visit conducted on 10/12/2023 were addressed during today's visit. LPAs were provided written documentation and the following deficiencies were cleared and plan of corrections letters provided:
- proof of quarterly emergency disaster drills (Health and Safety Code 1569.695(c))
- infection control plan (Regulation 85095.5(c))
- administrator certification (Regulation 87405(a)); cited during visit on 10/12/2023 and 10/23/2024
No Deficiencies Cited during Visit.
Exit interview conducted. Copy of report and LIC9102 (Technical Advisories/Violations) and Plan of Corrections Letters discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents. |