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STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES

AGING AND LONG-TERM SUPPORT ADMINISTRATION20425 72nd Avenue S, Suite 400, Kent, WA 98032-2388

October 4, 2016

RE: REDMOND SENIOR CARE AFH License #752655

Dear Provider:

The Department completed a follow-up inspection of your Adult Family Home onOctober 3, 2016 for the deficiency or deficiencies cited in the report/s dated July 29,2016 and found no deficiencies.

The Department staff who did the inspection:

RALUCA DONDOSREDMOND SENIOR CARE AFH5039 158TH AVE NEREDMOND, WA 98052

Jamie Singer, Community Complaint Investigator

Sincerely,

Bennetta Shoop, Field ManagerRegion 2, Unit EResidential Care Services

If you have any questions please, contact me at (253) 234-6033.

Completion DateLicense #: 752655

July 29, 2016

1Page 7of

REDMOND SENIOR CARE AFHPlan of Correction

STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES

AGING AND LONG-TERM SUPPORT ADMINISTRATION20425 72nd Avenue S, Suite 400, Kent, WA 98032-2388

Statement of Deficiencies

Licensee: RALUCA DONDOS

Jamie Singer, RN, Community Complaint Investigator

From:

DSHS, Aging and Long-Term Support Administration

Residential Care Services, Region 2, Unit E

20425 72nd Avenue S, Suite 400

Kent, WA 98032-2388

(253)234-6033

You are required to be in compliance with all of the licensing laws and regulations at all times to

maintain your adult family home license.

The department has completed data collection for the unannounced on-site full inspection of:

7/19/2016

REDMOND SENIOR CARE AFH

5039 158TH AVE NE

REDMOND, WA 98052

As a result of the on-site full inspection the department found that you are not in compliance with

the licensing laws and regulations as stated in the cited deficiencies in the enclosed report.

I understand that to maintain an adult family home license I must be in compliance with all the

licensing laws and regulations at all times.

The department staff that inspected the adult family home:

DateResidential Care Services

DateProvider (or Representative)


July 29, 2016

3Page 7of




WAC 388-76-10181 Background checks Employment Nondisqualifying information.

(1) If any background check results show that an employee or prospective employee has a

criminal conviction or pending charge for a crime that is not disqualifying under chapter 388-

113 WAC, then the adult family home must:(a) Determine whether the person has the character, competence and suitability to work with

vulnerable adults in long-term care; and(b) Document in writing the basis for making the decision, and make it available to the

department upon request.

Based on observation, interviews and record review, the adult family home (AFH) through its

Entity Representative (ER) failed to have written documentation of how the home determined 1

of 5 sampled staff (Staff C) who had non-disqualifying convictions or pending charges had the

character, suitability and competence to provide care to vulnerable adults. This placed the

home's residents (Residents #1-#5) at risk of harm from exposure and care from unsuitable staff.

Findings include:

Observations, interviews and record review took place 7/19/2016 unless otherwise noted.

During record review of staff files, Staff C had a Washington State name and date of birth

background inquiry (BGI) completed on 3/3/2016. The BGI indicated a negative action from

1994, " ". This is not a disqualifying crime under chapter 388-113

WAC.

The staff record had no documentation in writing to determine whether Staff C had the

character, competence and suitability to work with vulnerable adults.

In interview the ER stated that there was no character, competence and suitability documentation

for Staff C.

Observation found Staff C, with Residents #1-#5, providing unsupervised care in the home

throughout the day.

Attestation Statement

I hereby certify that I have reviewed this report and have taken or will take active measures

to correct this deficiency. By taking this action, REDMOND SENIOR CARE AFH is or

will be in compliance with this law and / or regulation on (Date)________________ . In

addition, I will implement a system to monitor and ensure continued compliance with this

cited deficiency.

Provider (or Representative) Date

This requirement was not met as evidenced by:


July 29, 2016

5Page 7of




This is a repeat or uncorrected deficiency previously cited on 3/9/2015

Attestation Statement

I hereby certify that I have reviewed this report and have taken or will take active measures

to correct this deficiency. By taking this action, REDMOND SENIOR CARE AFH is or

will be in compliance with this law and / or regulation on (Date)________________ . In

addition, I will implement a system to monitor and ensure continued compliance with this

cited deficiency.

Provider (or Representative) Date

WAC 388-76-10485 Medication storage. The adult family home must ensure all prescribed

and over-the-counter medications are stored:(1) In locked storage;

Based on interview and observation, the adult family home (AFH) through its Entity

Representative (ER) failed to ensure prescribed medication was kept in locked storage. This

placed the home's ambulatory resident (Resident #4) at risk of misuse of medication and harm.

Findings include:

Observations, interviews and record review took place 7/19/2016 unless otherwise noted.

During the environmental tour, a bottle of prescription 12% (a prescription

lotion) prescribed to Resident #2, was found in the main bathroom's medicine cabinet. The

bathroom is accessible to all residents.

In interview, Staff A was unaware the medication was in the bathroom. Staff A removed the

bottle of 12% and locked it with the home's other medications. Staff A stated

that Resident #4 was cognitively impaired.

Resident #4 was observed ambulating in the home without direct supervision.

This requirement was not met as evidenced by:

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