Routine inspection·September 29, 2023

Licensing Program Analyst (LPA) Lorena Casillas and Evelin Rios conducted an unannounced visit and were greeted by staff #1 (S1). LPA stated the purpose of the visit was to conduct an annual inspection. Staff confirmed there are four residents living at the facility. The facility is licensed for four residents of which four are ambulatory. Staff called the Administrator and the Administrator arrived at 10:15 am. LPAs toured the facility at 8:45am until 10:00 am Common Areas – LPAs observed the living room contained seating. The dining room contained dining room table and chairs. Kitchen – LPAs observed the knives were locked in a kitchen cabinet. The medications and first aid kit were locked in a kitchen cabinet. LPAs observed a two-day supply of perishable foods and a seven day supply of non-perishable foods. Resident Bedrooms - There are four resident bedrooms which are furnished with a bed, linens, nightstand, chest of drawers and a closet. Bathroom - There are two bathrooms located in the facility. LPA Rios tested the water temperature in two of two bathrooms at 11:05am in which temperatures were between 105 degrees F and 120.0 degrees F. Both bathrooms contained hand soap, paper towels, trash can, and grab bars. One out of two bathrooms did not contain slip resistant mat in the shower. S1 states that resident that uses that shower does not like shower mats and removes them. Administrator purchased a shower mat during visit. (LIC809C Continued on next page) (Continued from LIC809) Smoke/Carbon Monoxide Detectors – The detectors were tested at 11:04 am and were observed to be operable. Yard -LPAs observed that yard area was clean and free of clutter. At approximately 10:30am LPAs reviewed resident’s records. LPAs review of the medication administration record revealed that for Resident #2 (R2) their medication log and count for September 8, 2023, did not match. Administrator called staff #2 who explained that they did not recall what occurred on said date. Administrator then received a call from staff #3 (S3) and they explained that on said date they received a call from the pharmacy indicating that medication was to be suspended until lab results for R2 were received. LPAs interview with S3 revealed that S2 mistakenly logged in administering medication. At approximately 10:50am LPAs reviewed staff records. LPAs observed three of three staff records did not have the yearly required annual training. Administrator stated that they believed that the initial forty hours were sufficient. Two out of the three staff files reviewed were missing CPR and First Aid certifications. Two out of the three staff files reviewed were missing employee rights. Administrator was asked to produce liability insurance certificate but was not able to do so. Administrator states that they have it but will have to look for it. Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted, Appeal Rights discussed, and a copy of the signed report was provided.