Routine inspection·January 26, 2024

On 1/26/2024 at 10:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Janice Gombio and Campus Director, Isabel Poderoso. The facility’s fire clearance was approved for 31 non-ambulatory residents of which 12 residents may be under hospice care. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Freezer’s temperature was registered at 0 degree F while the refrigerator’s temperature was recorded at 40 degrees F. Hot water temperature was measured at 115.7 degrees F in a resident's bathroom. Grab bars and non-skid mats were observed. There were adequate lights in each room. Centrally stored medications were locked in medication cart. First Aid kit is complete. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detector was observed. Fire extinguishers were observed to be full and last serviced on 1/4/2024. Indoor and outdoor passages were free of obstruction. LPA reviewed 5 residents and 5 staff files starting at 1:10PM. LPA interviewed 3 residents starting at 12:00PM. LPA reviewed a sample of resident's medications starting at 5:20PM. LPA interviewed 3 staff starting at 5:50PM. At 2:00PM, LPA observed R1 and R2 does not have current medical assessments and R2 does not have current reappraisal needs and service plans on file. At 3:30PM, LPA observed S4 does not have health screening on file. (Continue on LIC809C...) At 5:40PM, LPA observed R2 ran out of medications (Primidone 250mg and Donepezil HCI 5mg). LPA was informed that R2 have not taken Donepezil for a few days. Staff stated that medications were ordered last week. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.