Routine inspection·October 16, 2023

Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by staff #1 (S1). S1 contacted the administrator Rita Morales. Rita met LPA shortly after. LPA explained to the administrator the purpose of the visit. LPA observed required postings in the entry area. Administrator had to leave to an appointment and designated staff Micaela Orozco to sign for the report. At 10:50 a.m. LPA conducted a physical plant tour to ensure the health and safety of the residents in care. The following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the kitchen. Bedrooms: There are (4) bedrooms of which four (4) are designated for residents' use. Two of the bedrooms are shared. Rooms occupied by residents were properly furnished with appropriate bedding and linens and with sufficient lighting. A hallway closet by the bedroom was observed to store extra linens, resident, staff records and medication. Bathrooms: There are two (2) bathrooms. Two (2) are designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) of two (2) bathrooms at 11:15 a.m. and read between 105 and 120 degrees Fahrenheit. Common Areas : These included the living area and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. (Continued on LIC809-C) The smoke alarms are hired wired and interconnected. A carbon monoxide detectors was observed in the hallway by the bedrooms. Administrator tested smoke and carbon detector at 11:09 a.m. and were observed to be functioning properly. The fire extinguisher is located in the kitchen and was observed fully charged. Surrounding Grounds : Entry/exits were free of obstruction. The outdoor area was free of hazards and has a covered patio with outdoor furniture. The laundry room leads to the garage and is kept locked and inaccessible to residents in care. Detergents and cleaning products are kept in the laundry room and garage locked. LPA observed a second refrigerator with food in the garage. Resident Files : LPA conducted a file review of resident records to insure compliance of licensing forms at at approximately 12:15 p.m. Records revealed a Medical Assessment was not on file before admitting resident #2 (R2). According to administrator they had requested it from the responsible person but had yet to receive it. Records for Resident #4 (R4) revealed they have dementia and did not have a medical assessment and a reappraisal done at least annually for 2021, 2022 and 2023. Staff Files : LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Staff records review of two (2) staff present at the facility revealed two (2) out of two (2) staff did not have current CPR and First Aid certification on file. Record review for two (2) out of two (2) staff revealed annual training was not on file. Medications : Medication and Medication Records were reviewed for proper documentation. LPA review of Centrally Stored Medication and Destruction Records (CSMDR) for six (6) of six (6) residents revealed revealed Resident #1's (R1's) medication label was altered by someone other then the dispensing pharmacist. According to administrator medication is provided by R1's responsible person and it was already altered when provided to the facility. At approximately 3:00 p.m. LPA interviews with residents and staff revealed facility does not have planned activities. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency observed during the visit (refer to LIC809-D). Exit Interview Conducted. Appeal Rights provided. A copy of the report Issued.