Routine inspection (multi-day)·January 30, 2024

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent visit for annual continuation. LPA met with Administrator, Gemma Deoso, who assisted with the inspection. The initial required-1 yr inspection was conducted on 01/29/2024. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools today for the remaining domains and observed the following: Personnel Records-Training: Six (6) staff files were reviewed. Proof of staff training, health clearance, vaccinations, food handling certificates, and 1st Aid/CPR training are current. Administrator's certificate expired on 04/06/2023, but proof was presented to LPA showing that renewal was submitted in March 2023. Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted in the 1st floor hallway and by the main entrance. Per Administrator, facility provides internet services to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted by the dining room. The facility has a Resident Council and council members/residents meet on a monthly basis. Food Service: Sufficient food supply is stored in the kitchen and (2) pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Phys ician orders for modified diets are on file. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: A total of eight (8) centrally stored resident medications were reviewed; containing 30-day supply of medications. LPA observed that the medications administered on 1/29/2024 to (1) resident (Resident #1/R1) were not properly documented/logged on the Medication Administration Record (MAR). A complete first aid kit is maintained in the medication room. Medical and dental transportation is provided. Resident Records/Incident Reports: A total of nine (9) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, Medication Records, and P & I Money Records. The Incident report binder was reviewed. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Records of resident Appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Eleven (11) residents are receiving home health services. Three (3) residents receive hospice care. Physician orders for postural support are on file. LPA observed half bed rails for mobility assistance in some resident beds. There are no residents with prohibited health conditions. Residents who are using oxygen have "No smoking In Use" signs posted on the residents doors. Per California Code of Regulations, Title 22, deficiency was cited. Exit interview conducted and a copy of the report and appeal rights were provided to Gemma Deoso, Administrator.