Routine inspection·December 7, 2021

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Caregiver Guillernia Hernandez and explained the reason for the visit. The RN Consultant Maria Alda Navallo Farren arrived shortly after. The physical plant was toured, resident files and medications records were reviewed, staff files were reviewed and food supply was inspected. Facility is licensed to serve 6 non-ambulatory residents age 60 and above and may retain one hospice resident. Facility has an approved fire clearance for one bedridden resident. LPA and Caregiver Guillernia Hernandez toured the facility which included the following: front yard patio, living room, dining area, kitchen, 2 bathrooms, 4 resident rooms, attached garage and backyard. Passageways and exits are free of obstruction. The water temperature was tested in the 2 resident bathrooms and measured between 110 - 112 degrees F which is within the required 105 - 120 degrees F. The resident bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Resident beds have the required linen and the linen is in good condition. Bedrooms also have sufficient closet space. There is extra linen in a closet near the dining area and a cabinet in the hallway. Smoke detectors were tested and observed throughout the facility and in each resident room. Carbon monoxide detector was tested and observed in the dining area. Auditory devices were seen on exit doors which are required for dementia residents and were operating a the time of visit. LPA observed 2 fire extinguishers in the kitchen and hallway which were fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps and cleaning chemicals are locked under the kitchen sink and are inaccessible to residents. The First Aid kit was inspected and is fully stocked with current manual, and it is locked in a cabinet near the kitchen. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed in the kitchen and garage. Medications, resident files, and staff files are kept in a locked cabinet near the kitchen. (CONTINUED TO LIC809C) The front yard patio and backyard are clean and there is a shaded seating area for the residents. No bodies of water were observed at the facility. LPA reviewed 5 staff files and observed the following: 5 out of 5 staff have criminal record clearances, 5 out of 5 staff have proof of in-service training, 5 out of 5 staff files have health screenings with TB information, and 1 out of 5 staff have current first aid/CPR certificates. Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), and Staff 4 (S4) did not have a current CPR/First Aid training certificate in their file. LPA reviewed 4 residents files and medications, and observed the following: 4 out of 4 resident have admission agreements on file, 4 out of 4 have their needs and services plans up to date, and 4 out of 4 have physician's reports on file and TB information, and 4 out of 4 have their medications documented properly and given as prescribed. Per California Code of Regulations, Title 22, and California Health and Safety Code, there was one deficiency observed during the visit (refer to LIC809D). Exit interview held and a copy of the report and appeal rights were provided.