Routine inspection·November 4, 2024

On 11/4/2024, Licensing Program Analyst (LPA) K.Kaur arrived at the facility unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit and was allowed entry into the facility by staff John Kevin Clemeno. Facility Staff contacted Administrator/Licensee, Susan Baal and Ulysis Baal. Licensees arrived a short time later. LPA toured the facility inside and out with staff. Facility observed to be clean, odor free and at a comfortable temperature. Pathways and doors were clear and free from obstruction. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. LPA observed sufficient seating in living room. Fire extinguisher last serviced 3/18/2024. LPA toured 4 resident rooms. Two rooms are single occupancy and two are shared. Resident rooms observed to have the required furnishings. At 11:34 AM LPA observed Bedroom #2 had a window screen that was torn. Tour continued to Kitchen and dining area which were clean and had sufficient seating. LPA observed 7-day supply of non-perishable foods and 2-day supply of perishable foods. Laundry area toured next to kitchen. LPA observed locked closet in the garage that has all chemicals. The exterior tour was conducted. The backyard was observed to have sufficient space and shade under a patio. Backyard gate is self-closing and self-latching. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report and ID Documentation. At 1:15 PM LPA observed no training for restricted health care conditions. Staff files were reviewed for good health and CPR/First Aid. At 2:51 PM LPA reviewed Centrally Stored Medication and Destruction Record (CSMDR) lists, MAR(s) and medication and observed 2 medications from 1 resident were not logged in the log. Medication counts also did not align with medication records for R1. R1 only had centrally stored medication records for current year and did not have previous records. Based on record review LPA observed Facility did not have a care plan from palliative agency for R2 Continued to Next Page Deficiencies are being cited in accordance with California Code of Regulations, Title 22, Division 6 on the attached 809D. LPA requested the following documents to be submitted to CCL by 11/11/2024: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file. Exit interview conducted and a plan of correction was reviewed and developed with Licensee/Administrator. A copy of this report and appeal rights was discussed and provided to Administrator, whose signature on this form confirms receipt of this document.