Follow-up·February 7, 2024

On 2/7/2024 at 10:15am Licensing Program Analysts (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management continuation visit to continue the post licensing initiated on 12/28/2023. LPA initially met with the staff on duty and explained the purpose of today’s visit. The facility supervisor was informed of the visit. Present during this visit were 2 residents in care with 1 staff on duty. From last visit, LPA was having technical issues with the CARE Tool. During this visit, the CARE Tool is still not accessible for utilization. During this visit, LPA conducted facility observation, resident file reviews, medication reviews, staff file reviews and facility file reviews. During the facility observation, LPA observed residents in care watching TV throughout the visit. Staff on duty interacted with residents every now and then. No other activities were offered to residents. Water temperature in 1 of 3 bathrooms was measured at 117 degrees F. Room temperature during this visit was measured at 71 degrees F. Facility have adequate food supplies with 2-day perishables and 7-day non-perishables were maintained for 2 residents. Overall, the facility was observed to be cleaned and free of obstructions. During the observation of the kitchen refrigerator, LPA observed an insulin injection pen stored in the refrigerator. LPA did not observe a thermometer in the refrigerator and unable to determine the temperature. Thermometer reading in the freezer was observed to be at 0 degree F. During staff file review, LPA observed 3 of 3 staff files that were available for review were observed to be incomplete. Additionally, 1 of 3 staff files are not available for review during this visit. Administrator's files are also not available for review at this time. Per staff, the files are not in the facility upon request. {Con't to LIC809-C} {Con't from LIC809} During resident file reviews, 2 of 2 resident files available for review were observed to be incomplete. 1 of 2 resident files were observed to be missing the needs and services plan. 2 of 2 resident files were observed to have missing PRN Authorization signed by their physicians. During medication review, LPA observed the following: some medications are expired, some medications were not recorded in the centrally stored medication form (LIC622), some medications do not have physician's order available for review, some prescribed medications are not available for review. Per review of the facility's medication administration record (MAR), 4 medications were observed to be missing staff initials since 2/1/2024. Due to insufficient time, this post-licensing will require a continuation visit. The Department will return at a later date to complete the issuance of additional deficiencies. Per California Code of Regulations, Title 22 and Health and Safety Codes, deficiencies were observed during this visit. Failure to correct deficiencies may result in civil penalties. Interview was held with the the staff on duty and a copy of this report and appeal rights were provided.