Routine inspection·July 18, 2024

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and was greeted by Rudolfo Macaliano (Caregiver) who allowed entrance to the facility, shortly after Evangeline De Casa (Administrator) arrived to assist with the visit, the purpose for today’s visit was explained. The facility is licensed to serve 1 6 ambulatory and 4 non-ambulatory residents ages 60 and above. There is an approved hospice waiver for 1 resident. The facility currently has 16 residents. - The facility is a single-story home located in Bellflower, Ca. A tour of the facility consists of 2 separate units and independent rooms with private bath along the back/outside. Main unit consists of kitchen, living room, dining areas, 4 resident bedrooms, 1 staff room/storage/medication room, 1 staff office. Leading to the exterior there are 6 private units with private baths. Detached garage and storage rooms/staff break room/backup refrigerator and freezer with food. Separate unit consists of 4 bedrooms and 2 bathrooms. There is a locked laundry area and linen storage near the separate unit. Facility has a large outside activity area, back yard, front yard and parking area in back yard. There is a fire sprinkler system throughout the facility. - LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit todays visit and the initial visit and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Operational Requirements: The facility has an approved fire clearance, there is a plan of operation with required Infection Control Plan and facility maintains liability insurance, however, the amount covered on aggregate was not the amount that facility is required to maintain (citation issued and will be documented on 809D). Fire Marshal arrived during visit and conducted an annual inspection with no issues. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. (Continued on LIC809-C) (Continued) No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked and are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. Last fire/disaster/earthquake drill was conducted on 7/3/24. Staffing : There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency. Personnel Records-Training : Staff has criminal record clearance, current First-Aid/CPR/AED training along with training in postural supports, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 4 staff files, Staff #3 and Staff #2 were missing training in Alzheimer’s and Dementia (citation will be issued and documented on 809D). Administrator Evangeline De Casa maintains a valid administrator certificate that expires on 11/8/2024. Resident Records-Incident Reports: Resident files are kept in a secure location (within staff office) and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files with no issues observed. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: Facility provides scheduled activities and have a variety of activities to choose from within the facility. There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: Medication is properly labeled and are centrally stored in locked staff room and locked cabinet, medication was observed to be in their original containers. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: There are no bedridden or residents with postural supports at this facility. - Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be documented on the LIC809-D. - Exit interview held, a copy of the report, appeal rights and list of confidential names to identify staff, were provided to Evangeline De Casa.