Magnolia Women’s Recovery Programs, Inc.

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Contact Information
Licensee Name
Magnolia Women's Recovery Programs, Inc.
3408 AndovreStreet, Oakland, CA 94606
Facility Name
Identification Number
01008C1 N
Reviews & Findings
Dates of Review
September 28 and 29, 2016
Type of Review
CO MPLIAN CE REVIEW
Deficiencies

1. Title 9, Section 10563 Accountability Class B

The above section states, “The license e, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.”

Th e license was deficient in meeting this regulation because a bottle of medications log for Resident was not documented in the medications log for Resident.

***This deficiency was corrected during the site visit***

The licensee was deficient in meeting this regulation because the number of multivitamin tablets documented in the medications log for Resident (76 tablets) is inconsistent with the container (78 tablets).

The licensee was deficient in meeting this regulation because was listed for Resident however, this cream was not in the medication box.

The licensee was deficient in meeting this regulation because was listed in the medication log for Resident however, this ointment was not in the medication box.

2. Title 9, Section 10566(b)(3} Admission Agreements Class C

The above section states, “Admission agreements shall specify the following: Those actions circumstances or conditions which may result in resident eviction from the facility.”

The licensee was deficient in meeting this regulation because the aforementioned information was not contained in the admission agreement.

***This deficiency was corrected during the site visit***

3.Title 9, Section 10566(c) Admission Agreements Class C

The above section states, in part, “Such agreements shall be dated and signed by the resident and licensee no later than seven (7) days following admission.”

The licensee was deficient in meeting this regulation because the licensee did not sign the admission agreement for Resident

4. Title 9, Section 10 57 2(f) Health Related Services Class B

The above section states, in part, “Licit medications which are permitted by the licensee shall be controlled as specified by the licensee’s written goals, objectives and procedures.”

The licensee was deficient in meeting this regulation because the following medications were not listed in the medications log for Resident.

The licensee was deficient in meeting this regulation because was listed in the medication log for Resident however, the container was not in the medication box.

The licensee was deficient in meeting this regulation because a container of was found in the medication box for Resident however, this prescription was not listed in the medication log.

The licensee was deficient in meeting this regulation because a loose tablet of plastic bag alongside bottles of prescription medication for Resident.

The licensee was deficient in meeting this regulation because the container for the tablets were being kept in a zip lock bag for Resident.

The licensee was deficient in meeting this regulation because the incorrect prescription number for was listed in the medication log.

The licensee was deficient n meeting this regulation because two containers of either the medications log or the destruction log for Resident.

5. Title 9, Section 10572(g) Health Related Services Class B

The above section states, in part, “Prescription medications which are not removed by the resident upon termination of services shall be destroyed by the facility administrator, or a designated substitute, and one other adult who is not a resident. Both shall sign a record, to be retained for at least one (1) year, which fists the following: (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed (4) The date of destruction.”

The licensee was deficient in meeting this regulation because the facility documents the date that medications are placed into the destruction box, instead of the date that the medications are actually destroyed.

The licensee was deficient in meeting this regulation because all medications to be destroyed are taken out of its containers and emptied into a medication storage box; therefore, inventory of medications to be destroyed was not possible.

Deficiencies 2

6. Title 9, Section 10573 Food Service Class B

The above section states, in part, “All food shall be selected, stored, prepared and served in a safe and healthful manner.”

The licensee was deficient in meeting this regulation because food was found in a drawer in bedroom #1.

**This deficiency was corrected during the site visit.**

• The licensee was deficient in meeting this regulation because expired tortilla chips and an unsealed loaf of bread was stored in the cupboard of the kitchen.

**This deficiency was corrected during the site visit.**

7. Title 9, Section 10581(a) Buildings and Grounds Class C

The above section states, “Facilities shall be clean, safe, and sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.”

The licensee was deficient in meeting this regulation because a knob on a drawer was missing in bedroom #5.

The licensee was deficient in meeting this regulation because the ceiling light was not working in the playroom.

The licensee was deficient in meeting this regulation because two electrical sockets in the playroom were not protected with covers.

**This deficiency was corrected during the site visit.**

Deficiencies 3

1. Section 11000 Program Evaluation

The above section states, “Each program shall have written evaluation plan for management decision making. Sufficient program data shall be collected to provide a meaningful assessment of the program’s progress in meeting its objectives.”

The provider was deficient in meeting this standard because a written document, describing the aforementioned was not found in the policy and procedure manual.

**This deficiency was corrected during the site visit.**

2. Section 12055 Referral Agreements

The above section states, in part, “Program policies and procedures shall identify the conditions under which referrals are made.”

The provider was deficient in meeting this standard because a written document, describing the aforementioned, was not found in the policy and procedure manual.

**This deficiency was corrected during the site visit.**

Deficiencies 4

3. Section 17015(b) Participant Files

The above section states, in part, “At a minimum, each participant file shall contain the following: Consent to follow-up,”

The provider was deficient in meeting this standard because a consent to follow up is not completed until successful discharge from the facility.

4. Section 19005(b) Personnel Policies

The above section states, in part, “The program shall maintain personnel files on all employees. Each personnel file shall contain: (2) Employment confirmation statement; (4) Salary schedule and salary adjustment information; (5) Employee evaluations,”

The provider was deficient in meeting this standard because the employment confirmation statement was not contained in the personnel record for Employee #8.

**This deficiency was corrected during the site visit.**

The provider was deficient in meeting this standard because the salary schedule was not contained in the personnel record for Employee #6.

**This deficiency was corrected during the site visit.**

The provider was deficient in meeting this standard because an employee evaluation had not been provided for Employees #2 and #4 for over two years.

5. Section 19010(c) Code of Conduct

The above section states, “The program shall post the written code of conduct in a public area that is available to participants.”

The provider was deficient in meeting this standard because written code of conduct was not posted in a public area.

Deficiencies 5

6. Section 20000 Fis cal Practices

The above section states, All programs shall have a written policy for the assessment and collection of fees”.

The provider was deficient in meeting this standard because a written document, describing the aforementioned, was not found in the policy and procedure manual.

**This deficiency was corrected during the site visit.**

7. Section 21000(a} Admission Agreement

The above section states, “The program shall have a written admission agreement that shall be signed and dated by the participant and program staff upon admission. The program shall place the original signed admission agreement in the participant’s file and a copy shall be given to the participant. The admission agreement shall inform the participants of the following: Fees assessed for services provided.”

The provider was deficient in meeting this standard because the program staff did not sign the admission agreement for Resident

8. Section 26010(a) Health and Safety

The above section states, “Programs shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of participants, employees and visitors.

The provider was deficient in meeting this standard because food was found in a drawer in bedroom #1.

The provider was deficient in meeting this standard because expired tortilla chips and an unsealed loaf of bread was stored in the cupboard of the kitchen.

The provider was deficient in meeting g this standard.because a knob on a drawer was missing in bedroom #5 .

The provider was deficient in meeting this standard because the ceiling light was not working in the playroom.

The provider was deficient in meeting this standard because two electrical sockets in the playroom were not protected with covers.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 20
Census: 18

TREATMENT CAPACITY:
Approved: 10
Census: 7