Routine inspection·September 19, 2023

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Care Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility. LPA met with Assistant Administrator, Luis Gabriel Santos, and explained the purpose for the visit. The facility is licensed to serve (6) elderly adults, ages 60 and over. It is approved for (6) non-ambulatory residents, of which (2) may be bedridden in room#3 only, and has a Hospice Waiver approved for (6). The facility is a single-story home, located in a residential area. The home consists of a living room, (4) residents bedrooms, (1) staff room, (2) resident bathrooms, a kitchen, dining room, attached garage, and shaded patio with seating in the backyard. The following (12) CARE tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Client Rights/Information, Client Records/Incident Reports, Food Service, Health Related Services, Incident Medical and Dental, Disaster Preparedness, and Emergency Intervention. During today's visit, LPA Maldonado obtained a copy of the client and staff roster, and conducted a tour of the physical plant with assistance of caregiver Melba Honrada. The following was observed: There is one central entry point for universal entry screening. The facility has a Mitigation Plan and Infection Control Plan approved and in place. There is sufficient PPE stored for 30-days and readily available for use, throughout the home and stored in the garage. The physical plant inside and outside is clean, sanitary and in good repair. All walkways, pathways, and ramps were observed to be free of obstruction/hazards. All resident rooms were inspected and observed to have the required furniture, bedding, linens, chair, adequate lighting, and closet space. At 12:50PM, LPA observed (2) resident beds to have full bed rails and (1) resident bed had half bed-rails. Each restroom was equipped with a toilet, shower, and wash basin. The restrooms had the required grab bars and non-skid mats. All kitchen and laundry equipment was observed clean and operational during today's visit. ( Report Continued on LIC809-C...) The water was tested and measured at 117.3*F in bathroom# 1 and 116.6*F in bathroom# 2, which is in compliance. The facility food was inspected and was observed to be sufficient for the amount of residents in care. The requirement was met for 2-day perishables and 7-day non-perishables available. One refrigerator inside the home and another freezer in the garage were observed fully stocked with a variety of nutritious foods. Kitchen cabinets and the garage were observed with a variety of non-perishables including vegetables, proteins, and cereals. Emergency disaster plan, personal rights and complaint procedures are posted as required. The smoke and carbon monoxide detectors were tested and observed to operate properly. Fire extinguishers were observed in the dining room and in the hallway, with current inspections and were noted to be fully charged. There is a working telephone in the facility for residents to use. No bodies of water were located on the premises. There is adequate seating in common areas for the licensed capacity. Cleaning supplies/toxins were observed stored and locked under the kitchen sink and in the laundry room, inaccessible to residents. Auditory devices were observed to be operational during the visit at each entry/exit. Sharps were observed stored in a kitchen cabinet, locked and inaccessible to residents. At 2:30PM, (3) resident files were reviewed. LPA discovered that the files for residents# 1-3 (R1-R3) were missing written orders for the bed rails, indicating the need for it, and files for R2-R3 were missing a Needs and Services Plan. R1's file was also missing their hospice care plan and has no updated medical assessment or appraisal, as required on an annual basis for residents with dementia. Medications and Medication Administration Records (MARs) were reviewed for (3) residents and observed to be documented properly and administered as prescribed. At 3:00PM, (4) staff files were reviewed. LPA discovered that the file for Staff# 1-3 (S1-S3) were missing proof of completed orientation and required annual training, the file for S4 was missing verification that they meet the educational requirements for Administrator, and proof of health screenings for S1, S2, and S4 were not located in their files. Interviews with S1-S3 were conducted and LPA was unable to conduct interviews with R1-R3 due to residents sleeping and/or having visitors at the time. Per California Code of Regulations, Title 22, deficiencies were observed during today's visit and will be cited on the LIC809-D. An exit interview was conducted with Assistant Administrator, Luis Gabriel Santos, and a copy of the report and appeal rights were provided.