Routine inspection·March 5, 2025

On this day, March 5, 2025, at 12:00 noon, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Charlainerose De Leon, and informed the reason for visit. LPA called and spoke over the phone with Mirriam Paras, administrator (ADM). ADM arrived at around 12:20 pm. LPA also met with other staff, Jonalyn Legarto, Melody Tria and Medelmira 'Mira' Cloma. LPA started the inspection with Charleinerose De Leon and continued with ADM. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was locked. Hot water temperature in common bathroom was tested and measured at 111.9 degrees Fahrenheit. Fire extinguishers were observed fully charge with tags showed serviced 9/03/24. Carbon monoxide and smoke detectors were tested and observed in operating condition during today's visit. Facility conducts disaster drills and records showed last conducted 1/16/25. LPA reviewed 5 residents and 5 staff files and interviewed 1 resident. Residents medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. LPA observed the following: -at 12:09 pm, pocket utility knife in unlocked in the drawer adjacent to the kitchen. -at 12:11 pm, food items in the refrigerator still in the shopping bags and box packaging materials. Sausage links and Bologna in opened plastic packaging material. -at 12:13 pm, rotten mushrooms, Serrano peppers, radish, celery and carrots with mold in another refrigerator. .....continued on 809C (page 2) Page 2 -at 12:27 pm, rusted dirty dining chairs. -at 12:32 pm and 1:02 pm, rusted trash cans on the 1st and 2nd floor bathrooms. -at 12:40 pm, cracked cement in between transition and heavily scratched door post in the common bathroom on the 1st floor. -at 12:45 pm, skin protector in the common bathroom. -at 12:47 pm, razor and skin protector in unlocked closet by the hallway adjacent to the common bathroom. -at 12:49 pm, rusted broken trash can, empty box, heavy stained non-skid mat, box with toilet seat and radio, bag of garbage, hoyer lift and bed with mattress in the ramp leading to the backyard. -at 12:54 pm, broken night stand door and heavily soiled upholstered chair in one of the resident's room. -at 1:00 pm, stained stairs steps' carpet covering. -at 1:02 pm, shower door with mildew and water damaged lavatory with stained faucet in the common bathroom on the 2nd foor. -at 1:15 pm, dusty exit door on the 2nd floor. -at 1:24 pm, worn out dirty and ripped patio chair cushions, rusted shopping cart, broken dishwasher, rusted broken trash can, broken construction cones and equipment boxes with trash in the backyard. -at 1:26 pm, unlocked cleaning supplies storage, construction tool, burnt out light bulbs, pails and gallons of paint in the side yard with unlocked gate. -at 1:29 pm, staff medications in unlocked small refrigerator in the area adjacent to the kitchen. -at 4:30 pm, S4, a cook, does not have food preparation training on file. S4 does not have LIC503 Health Screening Report on file. S3's LIC503 incomplete. -at 5:00 pm, staff, S5,does not have First Aid training. S5's required training for 2024 (first year of employment) incomplete. S3 and S5 do not have restricted health conditions training and have only 2 hours of medication training for 2024. -at 5:30, staff not CPR certified. -at 5:45 pm, resident (R1) has no pre-admission appraisal and LIC9172 Functional Capability Assessment. R1 and R3's bed rails have no doctor's order on file. .....continued on 809C (page 3) Page 3 -at 6:00 pm, residents' (R3, R4 and R5) LIC625 missing 2 pages. R3 and R4's LIC625 not signed. -at 6:40 pm, R5's two medications frequency of administration and date filled were incorrectly recorded on LIC622. Administrator to submit updated/current copies of the following by March 19, 2025: 1. Proof of $3M Liability Insurance coverage 2. Proof of Control of Property/Lease Agreement Deficiencies are cited from Title 22 California Code of Regulation, and listed on 809Ds. A $250.00 civil penalties for each of section # 87309(a), 87303(a), 87608(a)(3) and 87506(a) for repeat violations within 12 month period and will continue for $100.00/day until corrected. Deficiencies and plan and proof of corrections were discussed with the ADM. Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.