Routine inspection·August 29, 2024

Licensing Program Analysts (LPAs) Sandra Urena and Erica Mosley arrived at the facility unannounced at 11:53 a.m. to conduct a required annual inspection. The LPAs were greeted by staff and informed them of the reason for the visit. Administrator arrived about 30 minutes later. The LPAs and the staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 71 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and was last serviced on 01/09/2024. The LPAs observed required postings throughout the common space. The LPAs noticed that the Emergency Disaster Plan LIC 610E(Assignments) staff’s names need to be updated as some staff are no longer employed at the facility. KITCHEN: Knives are locked in a kitchen drawer stored inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 113.0 degrees Fahrenheit. During the inspection at 12:41 p.m., the LPAs observed the bottom sink cabinet which contained the chemicals to be unlocked and chemicals accessible to residents in care. The cabinet was secured during the visit. BEDROOMS: There are (6) resident bedrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. At the time of the visit two bedrooms’ (Bedroom #2 and #3) exit door were obstructed by furniture. The furniture was removed during the visit. The LPAs observed and detected the smell of urine in bedroom #5, staff were instructed to change the bed linens. There was a linen closet in the hallway with extra towels and linens. Continues on LIC 809C ... BATHROOMS: The facility has three bathrooms. Two bathrooms (one shared and one private) were clean and sanitary and in operating condition with grab bars and non-skid surfaces. One shared bathroom’s toilet -between rooms #4 and #5 was observed to have dried feces- and a razor accessible to residents in care. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 113.0 degrees Fahrenheit. OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. The washer and dryer are outside the facility. Detergent supplies are kept and locked in the laundry room. RECORDS: Records review began at 1: 36 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate annual training. Four out of four staff files are missing a current CPR/First Aid Certificate, and the annual 20-hour training. MEDICATIONS: Medications review began at 3:45 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area. Medications were audited and counted for accuracy of dispensing the medications. Two out of three medications audited were not properly documented on the centrally stored medications and destruction record. During the physical plant inspection, the LPAs observed that the staff had pill boxes for each of the six residents. The pill boxes had medications sorted out for each day of the week. INFECTION CONTROL : The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. .Citations were issued. Exit interview conducted. A copy of the report was issued.