Routine inspection (multi-day)·November 2, 2023

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Annual Continuation at the facility today continuing the inspection that began on 10/20/2023. At 9:50 a.m., the LPA met with staff and explained the reason for the visit. At 10:20 a.m., the Licensee arrived at the facility. At 10:10 a.m., the LPA conducted a brief physical plant tour to ensure there are no health and safety hazards. Starting at 10:11 a.m., the LPA conducted interviews with two (2) out of four (4) residents and two (2) staff. RECORD REVIEWS: Between 10:35 a.m. and 11:47 a.m., the LPA conducted a file review for all residents and staff regularly scheduled. Staff records were reviewed for documents including, but not limited to health screening, TB test, staff training records, and fingerprint clearance. The LPA was unable to identify the completed twenty (20) hours of annual training for staff. The LPA had several conversations with the Licensee with the goal of providing education in regard to staff training. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. The following was noted: Two (2) out of four (4) residents require updated appraisals/needs and service plan. Additionally, the LPA requested updated copy of valid liability insurance and Facility Emergency Plan. Between 1:20 p.m. and 1:50 p.m., the LPA conducted a review of medication and medication documentation with staff for four (4) out of four (4) residents and observed that all medications were properly documented. Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiency was cited (refer to LIC 809-D). The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights was provided.