Routine inspection (multi-day)·July 18, 2023

Licensing Program Analysts (LPAs) Angel Ascencio and Ashley Morgan conducted a Annual Continuation on the above facility. The initial annual was conducted on 06/12/2023. LPAs met with Director of Resident Care Services (DRCS) at 09:15 a.m. Entrance interview conducted. Resident Files: The LPAs observed ten (10) resident files. All files contained the proper documents necessary to stay in compliance. Staff Files: The LPAs observed ten (10) staff files. All staff files contained the proper documentation to be in compliance within state regulations. At 1:40 p.m. the LPAs interviewed five (5) staff members. No immediate concerns noted during the interviews. MEDICATIONS: Medications review began at 12:00 p.m. The LPAs reviewed medications for five (5) residents. Facility maintains a medication room, and medications are kept locked and inaccessible. For one resident (Resident #1) had an as-needed medication (Acetaminophen) that was administered two (2) times since 6/2/2023; however, staff documented that R1 was assisted with this PRN medication one (1) out of two (2) times. For three out of five residents (Resident #2, Resident #3, Resident #4), the pill count was off during the medication audit. At 1:37 p.m., the LPAs observed accessible medications in an unlocked office. The office was locked at the time of observation. At 4:00 p.m., the LPAs observed expired bread, expired milk, uncleaned kitchen area, food (bread, pies) not covered putting at risk for contamination, and cleaning substances stored within the food storage area. Continue on LIC 809 - C The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.