Routine inspection·April 22, 2023

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA Flores met with Tina Doan Caregiver and explained the reason for the visit. Maria Luisa Razo Activities Director arrived 30 minutes later. Facility is licensed to served 97 non-ambulatory residents over the age of 60, of which 30 may be bedridden, and has a hospice waiver for 30. The Facility is a single building located in a residential area and it consist of an office, a conference room, a medication room, a commercial kitchen, a dining room, a library, an activity room, 3 shower rooms, residents room, a courtyard, and a patio. LPA Flores conducted a tour of the facility with Tina Doan Caregiver and observed the following: Commercial kitchen's floors have stains, stove has grease and dust attached, warming trays have grease and burn leftovers, sink is dirty. Walking refrigerator has several moldy and rotten cabbages, a basket of brussel sprouts, and a tub of apples stored. A bag of oatmeal was observed in the pantry's floor and open without any covers or protection. Dining room and library's floor has crumbs under each table, and dry dirty stains in the floor throughout. Each resident's room has a working private toilet, sink and grab bars; sufficient lighting, furniture, and bedding supplies. Water temperature was tested in the following rooms #22, #28,#40,#44,#7,#14,#4 and tested between 97.1 - 121.6 degrees F., which is not within the required 105-120 degrees F. Shower room by room #23 was observed with grab bars and no skid mat available. Restroom by room #23 was observed in working condition water temperature was tested at 118.2 degrees F., and sink cabinet and drawers were observed with growing mold. Shower room by room #16 was occupied at the time of the visit and was not observed. Shower across from room #12 was observed with grab bars, no skid mat available. Laundry room was observed and the bottom of the back walk is peeling with water damage about 3 ft from the floor across the width of the wall. Large trash can adjacent to the laundry was observed with lid open twice, the trash can contained diapers and liners disposed. (CONTINUED LIC 809C) LPA conducted file review for 5 staff/ 5 residents and reviewed medication for 5 residents. Administrator does not have TB test on file and Med-Tech does not have medication training hours on shadowing completed or initial training signed, and a physician's report/TB is missing. During resident file review it was noticed that resident #5(R5) does not have a TB test on file and residents #1(R1) and #2(R2) do not have a signed admission agreement. Facility's outdoor area provides covered sitting area, no large bodies of water were observed. Facility has a sprinkle fire system throughout. Fire extinguishers were observed and last checked on 5/18/22. Local Ombudsman and Let Us Know posters were observed. Certificate # 60132006740 with expiration date 3/15/24 for Kandice Vergara was observed. A copy of liability insurance was provided to LPA . LPA Flores i nterviewed 4 staff and 4 residents. LPA was not able to complete the following domains during this visit and will return at a future time to finish the following: Planned Activities, Incidental Medical and Dental, Disaster Preparedness, and Resident with Special Health Needs. Exit interview was conducted with Maria Luisa Razo Activities Director and a copy of this report, LIC 809D, and appeal rights were provided.