Routine inspection (multi-day)·February 8, 2024

At approximately 8:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived unannounced to continue the annual required inspection. LPA met with Administrator Angela Stevens. At approximately 8:45AM, LPA reviewed 6 resident records. Six of six records contained current and signed admission agreements, current physician reports and resident care plans. Medication records are thorough and contained physician's orders for each resident. LPA will follow up with Licensee regarding recent changes to the Admission agreement and the increase in the cost of care that were not submitted to the Department. At approximately 10:45AM, LPA reviewed 6 staff records. 5 of 6 records did not contain documentation of completed annual training as required. Evidence of current first aid and CPR training were current. LPA and Administrator discussed staffing requirements throughout the building. Based on a review of resident records and staff schedules, LPA observed the facility does not have a sufficient number of staff to meet residents needs. At approximately 12:30PM, LPA reviewed the facility emergency disaster plan. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill in January 2024. Continued on LIC 809-C... While conducting this inspection, LPA followed up on an unusual incident report submitted by the facility on 12/26/2023. A staff member observed a resident waiting for their meal and gave the resident a plate containing turkey. The resident was allergic to turkey which was noted in the physician report and care plan. Facility contacted the physician and kept resident under observation. No ill effects were observed. Facility has implemented a new system in the kitchen for all staff to be aware of diet restrictions for each resident. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC309- Administrative Organization LIC500- Personnel Report LIC610E- Disaster Plan Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Angela Stevens and Appeal rights were given.