Routine inspection·January 12, 2024

Licensing Program Analyst (LPA) Wong 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 Adora Capa and the facility administrator Lea Chavez arrived shortly after. The facility is licensed for 6 residents with age range 60 and over. 6 Non-ambulatory and hospice waiver for 4. Currently, the facility has four hospice waiver residents, no home health, one on oxygen and no bedridden residents. 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 (PPE) supplies were observed. Facility Staff still practice hand washing and wear mask in the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirement: The facility has a Dementia Waiver in place. A Hospice Waiver for 4 residents is approved. All resident in the facility is non-ambulatory which is under the fire clearance approval. The facility does not have the actual liability insurance policy and they only have the quote for the liability insurance. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: kitchen, living room, dining area, 6 residents bedroom, 4 bathrooms, laundry room, pantry room and an attached garage. LPA inspected the resident room and each resident room has one bed, one chair, night stand, required furniture and beddings and sufficient lighting and closet space. LPA inspected the bathrooms, each bathroom is clean, sanitary and in a good working condition. Each bathroom has the required grab bar and non-skid mat. The hot water in all resident bathroom are tested between 110.8 and 114 degrees F. which is within the Title 22 regulation. The appliances in the kitchen and living room are working well. The sharp knives are stored and locked in the kitchen cabinet. All the cleaning supplies and chemicals are stored and locked in the garage. The extra linen and towels are stored in the cabinet near the residents room. LPA inspected the carbon monoxide detectors and smoke detectors and they are located in each bedroom and common area and they are all working well. The facility has a pool with water in the backyard. The pool water was clean and pool is surrounded by a locked gated. The passageway, walkway and patio are free of obstruction. Staffing: The facility has sufficient staffing in the facility. The facility has at least one person to have updated First Aid and CPR training certificate. Personnel Records-Training Information: All the staff work in the facility are over 18 yeas old and background checked and associated with the facility. All the staff file has the required documents include: health screening, TB test result, updated First Aid Certificate and required training hours. The administrator is Toby Miclat and her administrator certificate was expired on 10/12/2023 and currently the certificate is pending with CCL system since 11/28/23. Resident's right/Information: The complaint poster from LTCO and CCL are placed on the wall near the entrance door which included the resident personal right and theft and loss policy. The facility also has internet service which provide at least one internet access device such as computer or smart phone..etc for video conferencing with resident's family. Planned Activities: The facility has a sufficient space to accommodate both indoor and outdoor activities. Food Service: The facility has sufficient food supply for two days perishable and seven days non-perishable food in the facility. Currently there's no resident is on a modified diet that prescribed by the doctor. All the food in the facility are stored properly. Incidental Medical and Dental : LPA reviewed six residents' medication. R1's daily medication for Vitamin D3 and Omerprazole was not listed on the MARs and not sure if resident was taking the medication. The medication in the facility is centrally stored and locked in the kitchen cabinet. LPA also inspected the First Aid Kit in the facility and they have all the required supplies and updated Manual and stored and locked in the kitchen cabinet. Resident's Record-Incident Reports : A total of six (6) resident files were reviewed. They contained admission agreements, Physician's Reports, Appraisal, TB clearance, medical consent, and medication records. ***A total of 1 Dementia resident (R1) had Physician Report's older than 12 months. All the residents admission agreement is print double side of the paper. Disaster Preparedness: The updated Emergency and Disaster Plan LIC 610E is in place and posted on the wall. The facility did not conduct any emergency disaster drill last year. Resident's appraisal and Needs services plans are part of Emergency training. Residents with Special Health Needs: Four (4) residents receive hospice care. Half and Full bed rails for mobility assistance were observed in residents' rooms. LPA observed one resident (R2) has no doctor order for the half bed rail. Individual Service Plans and appraisals are on file. No Residents have prohibited health condition. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Lea Chavez. A copy of the report and appeal rights were issued.