Routine inspection·November 14, 2024

At 12:30 pm on this day, November 14, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with John Ronald Olivarez, licensee, and informed the reason for visit. LPA also met with staff, Maria Dolores Floriza, Macario Balingit, Jackylen Mendoza and Celeste Olivarez. LPA toured the facility inside out with licensee. LPA inspected the kitchen, dining area, living/tv room, common areas, staff and laundry room, bathrooms, side and backyard. LPA randomly selected 6 residents rooms for inspection. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Facility has 2 in 1 carbon monoxide detector that was tested and observed in operating condition. Hot water temperature in the common bathroom was tested. Disaster drill records reviewed. Fire extinguishers were observed fully charge with tags showed serviced September 17, 2024. LPA reviewed 5 staff and 5 residents files, and interviewed 2 residents. Medications checked, and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders. Facility does not handle residents' cash resources. The following updated/current documents were obtained on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) Licensee or administrator to submit by November 28, 2024 a copy of $3M Liability insurance certificate. ....continued on 809C (page 2) Page 2 The following deficiencies were observed, cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties. -at 12:35 pm, the 3 entrance/exit doors with no auditory signals. -at 12:39 pm, residents medications in 2 refrigerators unlocked. -at 12:44 pm, cleaning supplies/agents in unlocked cabinet in the kitchen. -at 12:47 pm, peritoneal cleanser and broken drawer in residents' room. -at 12:50 pm, wound cleanser in the cabinet under the sink in another resident's room. -at 12:55 pm, wound dressing, saline solution, grooming kit in the night stand drawer in another resident's room. -at 1:01 to 1:03 pm, insect killer, wound cleanser, staff medications, liquid laundry soap, Clorox spray in unlocked staff's room. -at 1:12 pm, water temperature at 127.4 degrees Fahrenheit. -facility has new administrator who took over the position when Adeliza Magallones resigned in September 13, 2024 and licensee failed to notify the Department. -at 2:30 pm, records showed disaster drills last conducted July 6 and 9, 2024. -at 4:00 pm. resident (R2) was discharged back to the facility on 7/2024 with LIC602A Physician's Report indicated stage 3 pressure injury and dependent on others with all activities of daily living (ADLs); however, R2 is able to feed self. LIC625 not updated. -at 5:00 pm, all 5 resident's half bed rails do not have doctor's order on file. -at 5:45 pm, resident (R1) doctor's order for Acetaminophen is 650 mg tablet, 2 tablets PRN but the medication in facility's hand is 325 mg tablet, 2 tablet PRN. Has doctor's order for Vascepa but facility does not have this medication. Order for ducosate sodium is 50 mg 1 capsule daily but medication on hand is 100 mg twice daily. Order for Atorvastatin is 20 mg 1 tablet at bedtime but medication on hand is 10 mg 1 tablet at bedtime and facility administers 10 mg. Order for Amlodipine is 5 mg once daily and the medication on hand is 10 mg once daily. ...continued on 809C (page 3) Page 3 -at 7:00 pm, resident (R5) doctor's order for prenisolone is 1 mg, 3 tablets daily but medication on hand is 1 mg, 1 tablet daily and facility administers only 1 mg 1 tablet daily. Has PRN order for Senna and Lorazepam and facility does not have these medications. Deficiencies and plan and proof of corrections were discussed with licensee. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.