Routine inspection·September 21, 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 Mariesol Gomez. There are currently 5 Dementia residents 60 years and older residing in the facility. Two (2) residents receives home health, and none are receiving hospice services. The inspection was completed using the CARE tools. Twelve (12) CARE tools domains were utilized during the inspection. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Visitors are no longer screened for COVID-19 or required to sign in. The facility has an Infection Control Plan and COVID-19 Mitigation Plan. Operational Requirements: A current Plan of Operation was reviewed. The facility has a Dementia Waiver in place. A Hospice Waiver for 4 is approved. A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 3 only. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current and expires 4/9/2024. A surety bond is not applicable. Facility does not handle resident's money. ****Narrative report continues next page.***** Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood consisting of 4 resident bedrooms (2 shared and 2 private), 2 bathrooms, living room, dining room, kitchen, den, live-in staff room, outdoor covered patio area, carport, and detached laundry room. 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. Kitchen drawers containing knives/sharp objects were locked and inaccessible to residents in care. The facility has one (1) fully charged fire extinguisher and a fire pull alarm. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature readings varied between low (92 DF - 113 DF) and high readings. Administrator adjusted the water heater and was advised to monitor water temperature for at least 2 days. Staffing: A total of five caregiver staff provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 12/1/2024. Personnel files were reviewed. It was noted that staff files had previous Licensee's names on some forms. Several staff files were not in premises. Electronic staff files and documents were provided during today's visit. Proof of staff training was reviewed. Current 1st Aid/CPR records are current. Resident Records/Incident Reports: A total of five (5) resident files were reviewed containing admission agreements, Physician's Reports, Appraisals, TB clearance, COVID-19 vaccine cards, 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. 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. Physician orders for a modified diets is in place. Incident Medical and Dental: 30-day supply of resident medications were observed. Centrally Stored Records for medications are kept. Resident (R3's) Rx order (1/6/2023) Lisinopril 20 mg/hydrochlorothiazide 12.5 mg is listed on resident records as "Lisinopril HCTZ 10-12.5 mg". Therefore, the exact physician order dosage was incorrectly documented on R3's records. Staff acknowledged they had not noticed that there was a difference in dosage on the medication bottle and their records. No physician order was on file. Citation was issued. Medical and dental transportation is provided by family members. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place and was posted today. The last emergency disaster drill was conducted 8/16/2023. Residents with Special Health Needs: Two (2) residents receive home health services. Postural support i.e. hoyer lift is used for one resident. Physician order is on file. A total 4 residents [ R2, R3, R5 & R6] had full and/or two half rails side by side, converting it into full rails on each side, and none of the residents are in hospice. Citation was issued. No residents have prohibited health conditions. Per California Code of Regulations, Title 22, deficiencies were cited. ***Due to technical issues Administrator did not sign the report, nor was the report and appeal rights issued. On 9/22/23, LPA spoke to Administrator and sent the report/appeal rights and requested the report be signed and returned to LPA.