Routine inspection·May 22, 2025

On 5/22/2025, Licensing Program Analysts (LPAs) Daiquiri Boyd and Shawna Doucette arrived unannounced at the facility to complete an Annual Inspection. LPAs were met by caregiver staff and were told they had called Administrator (AD) Nicole Morehead and that she was pulling in. LPAs toured the facility with AD. Kitchen toured, there was not a sufficient supply of food observed for perishable, as there was only a half gallon of milk for the 34 residents in the facility. There was not a sufficient supply of non-perishable foods on hand, LPAs did not observe a 7 day supply of goods. Facility had menus posted on the dining room wall. LPA's took photos of freezer, refrigerator, and dry goods shelves. In the dining area there is an ice machine where they can get self service ice. AD stated that they receive a weekly supply of food, due for delivery tomorrow and the supplier is Jordano's Supply. There is no supply of diabetic diet foods on hand for residents. There were 18 resident bedrooms, each room houses 2 residents. Resident rooms all had their own bathrooms. Temperature in room #9 was recorded by LPA at 135.1 degrees F. LPAs observed proper hand rails and grab bars. Non-skid mats were available. Room #16 was toured and the water temperature measured at 127.1 degrees F. Hand washing and personal hygiene items were seen on hand. A tour of the outside was conducted and a shaded courtyard was observed with tables and chairs for residents to sit and visit. There was an area with trash receptacles appropriate for smoking. 6 resident files and 4 staff records were reviewed. AD reports that they currently only have one bedridden client. Current first aid and CPR were reviewed and found to be in compliance. (continued on next page) LPAs reviewed Training Logs and found that only 2 hours of training were completed for the combined dementia and hospice care. R1 has a LIC602 that states that she is bedridden, but the AD stated that she is not bedridden and can repossition. R2 has no care plan from Bristol Hospice Agency. R3 has home health care, but there is no written plan of the division of care and responsibilities of the facility. R3 has a pressure wound and the level of the ulcer is not mentioned in the Home Health Care file, but LVN Naomi Medina on staff, stated that the number assigned is 2. R6 has no Admission Agreement with Kern Regional Center. R7 has a skin tear that appears inflamed, LPAs verified care plan on file and found to be appropriate. LPAs observed the medication cart in the dining room area. A check of the medications was done by LPA Boyd. LPA Boyd observed that R6 had missed a medication on 5/9/25 and the medication administration log showed that he missed the medication on this date due to being in the hospital. All medications observed to be logged properly. In the hallway of the facility is a locked storage closet which holds the diabetic medications and/or testing strips. There is a refrigerator in this closet that holds all diabetic and all other refrigerated medications. This refrigerator was observed to be locked upon entry to this closet. In the corner of this closet was a large (approximate 25 gallon) trash can size bio-hazard container with dispensed diabetic injectable pens. On top of this bio-hazard container was several resident snacks, for example: several open boxes of crackers(Ritz, Lays), an open coffee creamer. Pictures were taken by LPAs. There is a room called the "TV room" which is where the lights signal for the call buttons that are in each of the resident rooms. There is an overflow med cart in this room that stays locked. Postings for the facility were observed at the end of the hall by entrance doors. Disaster and Emergency plan was not posted and was not complete in the office computer. Last fire drill was on 4/30/25. LPA asked for an updated Disaster Plan.