Routine inspection (multi-day)·January 29, 2025

At 9:40 a.m.,Licensing Program Analyst (LPA) Evelin Rios met with caregiver Dulce Villeros. At approximately 10:15 a.m. LPA spoke to the administrator Jojo Cajayon by telephone and explained the purpose of the visit was to continue the annual visit. An entrance interview was conducted. On 01/28/2025 LPA initiated required annual visit. Due to time constraints LPA was unable to complete the annual visit. Today LPA will complete the annual visit. LPA could not locate Infection Control Plan for facility but did find records a Mitigation Plan Report was approved on 02/16/2021. On 01/28/2025 LPA started to review five (5) of five (5) resident records and did not yet review medications and medication records. On 01/29/2025 at 9:59 a.m., LPA continued to review resident records. Resident #6's (R6's), Physician's Report (LIC 602A) revealed they are bedridden. LPA's review of facility sketch on file with Community Care Licensing Division (CCLD) and sketch posted on the facility walls indicate bedroom #6 is designated as a non ambulatory room and bedroom #3 is designated as the bedridden room. On 01/28/2024 at 3:31 p.m. LPA interviewed R6 and they informed LPA they could reach for items but needed assistance to reposition to the left or right. LPAs telephone call with the administrator, revealed they believed the inspector that conducted the fire clearance visit had indicated any room in the facility with a door was cleared for a bedridden resident. LPA review of the Fire Safety Inspection Request (LIC850) indicated the facility does have a capacity for one (1) bedridden resident without indicating which room is designated to house bedridden resident and without the comment that any room may be used to house the one (1) bedridden resident. Administrator agreed to submit required documentation to change status designation of bedroom #6. LPA spoke with Administrator regarding missing bed rail orders for three (3) out of five (5) residents. Administrator indicated they would obtain orders from family members. LPA advised it must be a written order from a physician. Administrator informed LPA they would be removing bed rails until an orders were obtained. (Continue to LIC809-C) (Continued from LIC809 Case Management Annual Continuation) At 11:02 a.m. LPA reviewed medication and medication records of five (5) out of (5) five residents. LPA observed the following: Resident #1's (R1's), Medication Administration Record (MAR) did not have records indicating they were given 26 pills out of a 30 quantity PRN medication. Resident #2's (R2's), MAR for December 2024 and January 2025 did not have two medications listed. Medications were observed in resident's medication bin with other prescribed medication. Resident #4 (R4), has one medication labeled to give 2 times daily, review of Medication Administration Record (MAR) only indicated staff were providing it one time at 8 p.m. Staff stated they provide it twice daily. At 11:38 a.m. LPA spoke to the administrator by telephone and went over medication and medication record concerns. Administrator stated they did not have written orders from a physician for medication for four (4) out of five (5) residents. LPA also discussed with administrator that staff indicated they poured medication running low from one medication to the new medication bottle with start date 02/01/2025. Deficiencies cited on todays visit (refer to LIC809-D). Immediate Civil Penalty Assessed on todays visit (refer to LIC421IM). Technical Violations issued. Exit interview conducted. Appeal rights provided. Copy of report provided.