Routine inspection·June 7, 2023

On this day, June 7, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Gina Tolentino. LPA called and left message on Sharon Aranha's (administrator) voicemail. and informed the reason for visit. LPA also met other staff, Rogelio Tolentino. The administrator arrived after 45 minutes. Facility has submitted the LIC808 Mitigation Plan but not the LIC9282 Infection Control Plan. LPA inspected the facility inside and out including but not limited to common areas, bedrooms, bathrooms, living and family rooms, kitchen, dining area, front, side and backyard. Facility has sufficient perishable and non-perishable foods. Facility has smoke and carbon monoxide detectors that were tested and observed functional. Hot water temperature in one of the ensuite bathrooms was tested, and measured at 109 degrees Fahrenheit. First aid kit was observed complete with manual. LPA reviewed 4 residents and 5 staff files, and interviewed 2 staff. Medications were checked and compared with records. Facility does not handle residents' cash resources. LPA observed the following: -At 11:23 am, Pepto Bismol in the refrigerator. -At 11:30 am, lancets and Glucose test solution on the desk by the dining area. -At 11:31 am, fire extinguisher fully charge but tag showed serviced March 12, 2021 -at 11:39 am, wound cleanser and antifungal powder in one of the resident's rooms. -At 11:44 am, broken toilet paper holder in one of the ensuite bathrooms. -At 11:46 am, shovel in the backyard. .......continued on 809C -Facility does not have record of disaster drill being conducted every 3 months. Administrator stated they only watch video, and do not do the actual drill. -At 3:10 pm, 4 out of 4 staff has not completed the required f o ur hours training specific to postural supports, restricted health conditions, and hospice care -At 4:45 pm, observed resident (R1) has doctor's order on file for 11 medications, but medications on facility's hand is only 7 of which 2 is not included on the order. Facility does not have the 5 medications on the doctor's order. Medication labels showed filled dates April, May & June 2023 and these were not recorded on LIC622 Centrally Stored Medication and Destruction Record. -At 5:15 pm, resident (R2) has 3 medications on facility's hand but no doctor's order on file. LIC622 on file is incomplete (no name of resident; quantity of meds received and date started not recorded). R2's bed has half bed rails but no doctor's order on file. -Resident (R3) has Vitamin and supplements on hand but no doctor's order on file. R3's bed has half bed rails but no doctor's order. -Resident's (R4) has bed rails but no doctor's order on file. LIC602A Physician's Report showed R4 is dependent on others with all activities of daily living (ADLs). Administrator to submit the following updated documents by June 21, 2023: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. LIC9282 Infection Control Plan 4. Proof of $3M liability insurance coverage Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.