Health check·June 21, 2023

On this day, June 21, 2023, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a health and safety inspection as a result of the Department receiving a priority 1 complaint (Complaint # 15-AS-20230615163239). LPA met with Executive Director (ED) Jeffrey 'Jeff' Freeth, and informed the reason for visit. LPA toured the facility including but not limited to common areas, ensuite and common bathrooms, dining area, kitchen, activity room, theater. LPA randomly selected total of 5 bedrooms on the first, second and third floors. LPA tested the hot water temperature in one the residents' ensuite bathroom which was measured at 117.3 degrees Fahrenheit. At 3:24 pm, LPA observed the following in one of the resident's (R1) room: All purpose cleaner; Vicks VapoRub ointment; acid control medication. LPA interviewed staff (S1) who stated R1 is on Medication Management Program. Review of records revealed R1 has dementia and that R1's medications need to be managed. R1's Service Plan indicated R1 is on Medication Management Program. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the ED. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.