Routine inspection·September 30, 2024

On 9/30/2024, Licensing Program Analysts (LPAs) J. Leffall and M. Garza arrived at the facility unannounced to conduct the Required Annual Inspection. LPAs were greeted by Staff (S1) Kimberly Clark, stated the purpose of the visit. Administrator (A1) Carlos Santos arrived sometime later. LPA’s conducted tour of facility with S1. 5 Residents present during inspection tour. Upon facility entrance LPAs observed no chime alarm sound on front door. The facility was observed to be at a comfortable temperature, clean, in good repair with no inside passageway obstructed or fire hazards. Fire extinguisher was observed with a service date of: 8/19/2024. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be improperly stored in freezer and refrigerator. Refrigerator temperature was observed maintained at 40 degrees F. and freezer was observed maintained at 0 degrees F. LPAs observed improperly stored food with no dates. Knobs were observed accessible and exposed on top of stove. LPAs observed pantry area with adequate non-perishable foods for residents. Chemicals were observed accessible in 2 of 4 bathrooms and 1 of 5 resident bedrooms. Resident rooms toured and observed with required furnishings and lighting. LPAs observed securely fastened grab bars next to toilet and all tub/shower areas. LPAs observed restrooms with toilet paper/paper towel not on holders in bathrooms. 1 out of 4 bathrooms observed to not have a non-skid mat in shower. Water temperature measured at 107.2 degrees F in bathroom #1, and 110.8 degrees F in bathroom #2. Laundry room hallway observed to have small hole in the wall. 2 out of 5 client room carpets observed to be in need of cleaning and torn at doorway area. Backyard observed with self-latching gate for exit. 2 chairs on patio area observed blocking walkway. Water hose observed in the middle of walkway in backyard. Backyard observed to have no shade over outdoor table. A gate was observed broken that needs to be secured. CONT.... CONT..... LPAs completed a medication audit. Medications were stored in a locked medication room in a medication cabinet. MARs and medications were reviewed. Review of Centrally Stored Medication Record revealed R1’s medication log was incomplete. Based on record review, LPAs observed 1 out of 1 residents medication count was over the required amount. A sample of staff files reviewed. A sample of resident’s files were reviewed. 1 of 3 resident files reviewed, needed an updated LIC-602. The following documents are being requested and submitted to Fresno CCL by: 10/10/24. Forms requested: LIC 308, LIC 309 (if applicable), LIC 500, LIC 610D, LIC 9282, current Administrator certificate, and control of property. A copy of this report and appeal rights was provided to Administrator, whose signature on this form confirms receipt of this report. LPAs observed missing Restrictive Health Conditions, and Hospice/End of Life training's. Deficiencies cited on attached 809D in accordance with California Code of Regulations, Title 22,Division 6. An exit interview completed with Administrator, Carlos Santos. Report signed on-site; a copy of this report, deficiencies, TV’s and appeal rights were provided.