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32 | Health-Related Services & Records
Three (3) resident files were reviewed. Files contained required documentation, including Admission Agreements, signed consents, Physician’s Reports documenting TB results and ambulatory status, and Resident Rights acknowledgments.
During record review, LPA observed that R1 had a physician’s order for half bed rails; however, full bed rails were in use at the time of inspection. LPA also observed that R1 and R2 did not have physician’s orders on file authorizing the use of half bed rails.
Medications for three (3) residents were reviewed. Medications were centrally stored and secured in a locked cabinet near the kitchen. During the medication record review, LPA observed that the Medication Administration Records (MARs) contained missing administration notations. LPA also observed that staff administered medication when residents’ blood pressure and/or heart rate readings were outside the parameters specified in the physician’s orders. The physician’s orders directed staff to withhold the medication when the specified blood pressure or heart rate parameters were met; however, the medication was administered. Therefore, the physician’s medication orders were not followed as prescribed.
Disaster Preparedness
Last fire/earthquake drill was conducted on September 14, 2026, with logs available. LIC 610D Emergency Disaster Plan was in process of being updated. Emergency supplies (water, food, flashlights, batteries, first aid) were observed.
Personnel Records & Training
Five (5) staff files were reviewed and contained required documentation, including criminal record clearances, current CPR/First Aid certifications, and TB screenings. Administrator Jerelyn Toparco’s Administrator Certificate was observed to be current and valid through May 16, 2028. Staff training records were not available for review at the time of the inspection.
An exit interview was conducted with Corinthian Toparco. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided.
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