Routine inspection·June 23, 2023

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Maria Lerma. The purpose of the visit was discussed telephonically with Administrator Herminia Pegolla telephonically. There are currently 5 elderly residents with Dementia 60 years and older residing in the facility. Zero (0) residents are enrolled in hospice or home health at this time. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in log. The facility submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirements: A current Plan of Operation and Personnel files were reviewed. The facility has a Dementia Waiver in place. A Hospice Waiver for 6 is approved. A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 2. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expired 7/1/2023. However, other parts of coverage are current. A surety bond is not applicable. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed for six (6) non- ambulatory residents, of which 1 may be bedridden. It consists of a kitchen, living room, dining room, activity room, covered patio area, backyard, laundry room, 3 resident bedrooms, 1 staff room, 2 bathrooms, and detached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances were observed unlocked in the laundry room. The laundry room was not locked. Kitchen knives were unlocked in cabinet and drawers. Citations were issued. The main entrance door auditory alarm was turned off and side door's auditory alarm is not operable. The facility has three (3) fully charged fire extinguisher. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Staffing: A total of 3 regular caregiver staff & 4 on-call staff provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificates expires 10/16/2023. Personnel files/training were reviewed; with the exception of on-call staff (S2's) file. Staff (S5) does not have a file, but is cleared and associated. Citation was issued. Resident Records/Incident Reports: A total of five (5) resident files were reviewed; which included admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information. Resident (R5) did not have a current Physician Report. RCFE complaint poster and Personal rights were observed posted. ***narrative continues next page*** Resident Records/Incident Reports: A total of five (5) resident files were reviewed. Files were observed to be incomplete. They were missing admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information. RCFE complaint poster and Personal rights were observed posted in the facility entrance area. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. No Physician orders for modified diets are on file. Sanitation practices and kitchen cleanliness was observed. Incident Medical and Dental: Three (3) centrally stored resident medications were reviewed; containing 30-day supply of medications. Resident (R1) had medications in their room drawer that were unlocked. Medical and dental transportation is provided by family members and staff. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. The last emergency disaster drill was completed on 3/6/2023. See next page Residents with Special Health Needs: No residents are receiving home health or hospice services. Postural support physician orders are on file. Half rails for mobility assistance were observed in some resident beds. Individual Service Plans and Appraisals were observed in resident files. No residents have prohibited health conditions. NOTE: Change of Administrator is pending. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with staff Maria Lerma. A copy of the report and appeal rights were issued.