Routine inspection·May 31, 2024

Licensing Program Analysts (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Stacy Lopez, Manager of the home, and was granted entrance to the facility. Administrator and Owner Linda Morales arrived shortly thereafter. There are five (5) residents currently living in the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control practices and Personal Protective Equipment (PPEs) were observed. · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) non-ambulatory residents and is approved for a hospice waiver for one (1) resident, however there are two (2) residents who are identified as bedridden in their physician’s report. The facility consists of a living room, a dining room, four (4) resident rooms, two (2) resident bathrooms of which restroom #1 (R1) had a hot water temperature reading of 108.2 Degrees F, and restroom #2 (R2) had a hot water temperature reading of 109.2 Degrees F, a kitchen, a backyard area that contains a shaded area, and a separate storage room which contains the facility’s emergency food supply along with the washer and dryer machines. Knives, chemicals, and cleaning supplies are kept locked and away from residents in the storage room and underneath a cabinet in the kitchen. The facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has one (1) fully charged fire extinguisher located in the kitchen of the facility. There were no sharp objects that were left accessible to residents. · Water temperature readings were within the required range of 105 - 120 degrees Fahrenheit. · The See Something, Say Something (PUB 475) poster was not located within the facility. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by the City of Pasadena Fire Department for a capacity of six (6) non-ambulatory residents and is approved for a hospice waiver for one (1) resident. · Care and supervision to meet the clients’ needs was observed. Staffing: · A total of forty-five (45) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training. · Documented annual retraining on dementia care, hospice care, and postural support care was not found within the facility. · Administrator’s certificate expires on 1/3/2025. Resident Rights/Information: · Physician orders were reviewed for five (5) resident files. · Medications were also reviewed for five (5) residents. Resident Records/Incident Reports: · Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. One resident’s admissions agreement was not dated since their admission on 4/1/2024. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan was publicly posted and found within the facility. · An emergency and disaster drill was last conducted on 5/4/2024. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs: · The facility has a non-ambulatory fire clearance for each room that will be used to accommodate residents with a dementia diagnosis. · Staff that provide direct care to residents with dementia receive training related to dementia care. · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.