STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 7575 METROPOLITAN DR. #109 SAN DIEGO, CA9!108

FACILITY EVALUATION REPORT

FACILITY NAME: PACIFIC PLACE A MERRILL GARDENS COMMUNITY ADMINISTRATOR: KAREN ENCISO 3500 LAKE BLVD. ADDRESS: OCEANSIDE STATE: CA CITY: 175 CENSUS: 135 CAPACITY: UNANNOUNCED Case Management TYPE OF VISIT: Chad Orrnsby, General Manager MET WITH:

FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED:

374600707
740

(760)414-9411 92056 02/18/2011 10:45 AM 12:30 PM

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NARRATIVE LPA's Robbie Jackson and Christine Focosi-McKelvey conducted a case management at the facility. LPA met with Chad Orrnsby, Executive Director. Facility has sent several fact sheets of incidents that have occurred at the facility including the elopement of a resident from the dementia unit, four (4) separate medication errors including resident #1 did not receive her medication from 2/1/11-2/4/11, resident #2 did not received his third dose of Sinement as prescribed for 4 days, resident #3 received 150mg of the medication Tarce instead of the prescribed amount of 100mg for an unknown period of time due to pharmacy bubble packing mistake, resident #4 received 7 doses over 7 days of 200mg versus the prescribed 50mg by her doctor; AH the fact sheets state that a full incident report will follow next week. No follow up incidents have been received. The following deficiencies were cited per Title 22, Chapter 8, Division 6. A civil penalty of $150 is being assessed for the second citation of inadequate staff within a 12 month period. The first citation was issued 1/11/11. An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Gladys Figueroa LICENSING EVALUATOR NAME: Robbie Jackson LICENSING EVALUATOR SIGNATURE:

TELEPHONE: (951)204-6346 TELEPHONE: 619-318-7620

DATE: 02/18/2011

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FACILITY REPRESENTATIVE SIGNATURE:

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This report must be available at Child Care and Group Home facilities for public review for 3 years.
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DATE: 02/18/2011

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I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

CCLD Regional Office, 7575 METROPOLITAN DR. S109 SAN DIEGO, CA 92108

FACILITY EVALUATION REPORT (Cont)

FACILITY NAME: PACIFIC PLACE A MERRILL GARDENS COMMUNITY' DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date / Section Number DEFICIENCIES

FACILITY NUMBER: 374600707 VISIT DATE: 02/18/2011 PLAN OF CORRECTIONS(POCs)

1 see POC on previous page. 2
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Type A 02/22/2011 Section Cited 87411(a)

1 Continued from personnel requirements on 2 previous page-A civil penalty of $150 is being 3 assessed for the second citation within a 12 month 4 period. The first citation was issued 1/11/1 1 . 5 6
7 1 A written report shall be submitted to the licensing

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7 1 Facilty will send completed incident reports of fact 2 sheets previously submitted by the POC date. In 3 the future, facility will send completed incident 4 reports to CCL by the 7 day requirement. 5 6 7

Type B 02/22/2011 Section Cited 87211(a)(1)

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agency and to the person responsible for the resident within seven days of the unsual occurrence of any events that effects the health and safety of the resident This report shall include the resident's name, age, sex and date of 7 admission; date and nature
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of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Facility has submitted fact sheets of incidents occurring at the facility and not full incidents reports 12 with the required information. 13
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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: Gladys Figueroa LICENSING EVALUATOR NAME: Robbie Jackson LICENSING EVALUATOR SIGNATURE: TELEPHONE: (951)204-6346 TELEPHONE: 619-318-7620

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FACILITY REPRESENTATIVE SIGNATURE:

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I acknowledge receipt of this form and understand my appeal rights as explained and received.
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DATE: 02/18/2011

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION CCLD Regional Office, 7575 METROPOLITAN DR. #109 SAN DIEGO, CA 92108

FACILITY EVALUATION REPORT (Cont)

FACILITY NAME: PACIFIC PLACE A MERRILL GARDENS COMMUNITY DEFICIENCY INFORMATION FOR THIS PAGE: Deficiency Type POC Due Date / Section Number

FACILITY NUMBER: 374600707 VISIT DATE: 02/18/2011

DEFICIENCIES

PLAN OF CORRECTIONS(POCs)

1 Incidental Medical and Dental Care Services. Type A j r02/22/201 1 Section Cited 87465{c}(2)

1 General Manager stated that he and the new nurse

2 have conducted an audit of all the medication and 2 Once ordered by the physician, nonprescription 3 PRN medications shall be given in accordance with 3 have found a numerous amount of additional

4 the physician's directions. Facility sent to CCL four 4 errors. General Manager also stated that there is 5 (4} separate medication errors including resident #1 5 one employee has been suspended and two 6 did not receive her medication from 2/1/11-2/4/11, 6 additional employees are being suspended for 5 7 days because of the 7
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resident #2 did not received his third dose of Sinement as prescribed for 4 days, resident #3 received 150mg of the medication Tarce instead of the prescribed amount of 100mg for an unknown period of time due to pharmacy bubble packing mistake, resident #4 received 7 doses over 7 days of 200mg

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errors and possibly terminated. General Manager states that training has began to take place with training from LVN's from Accent Care and R &R staffing. Q & A nurse from corporate will also come and give training in the near future. General managers will send proof of training to CCL by the POC date.

Type A 02/22/2011 Section Cited 87465(c)(2)

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1 versus the prescribed 50mg by her doctor

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Type A n?/??/?oi 1 Section Cited 874 11 (a)

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Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. Facility sent to CCL facts sheet of resident #5 eloped out of building 200 and was picked up by staff outside the fire station.

1 Facility will submit a policy on resident elopement 2 along with a training for staff by the POC date. A 3 non compliance conference is being planned.

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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: Gladys Figueroa LICENSING EVALUATOR NAME: Robbie Jackson LICENSING EVALUATOR SIGNATURE: TELEPHONE: (951) 204-6346 TELEPHONE: 619-318-7620

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FACILITY REPRESENTATIVE SIGNATURE:

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I acknowledge receipt of this form and understand my appeal rights as explained and received.

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DATE: 02/18/2011