Routine inspection·October 14, 2024

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. The purpose of the visit was explained to DSP Elmer Santos. Assistant Administrator Danielle Maximo arrived shortly after. The facility is licensed for 4 elderly developmentally disabled residents 60 years and older. The facility is licensed as a level 4C RCFE vendored by San Gabriel/Pomona Regional Center. The following 12 Care Compliance and Regulatory Enforcement (CARE) tool domains were utilized during the inspection. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed. The facility has a supply of Personal Protective Equipment (PPEs). Operational Requirements: A hospice waiver for 4 and Dementia waiver is in place. A fire clearance for 4 non-ambulatory residents age 60 and above, of which 1 resident may be bedridden in room #4. Facility handles resident P & I monies and has a current Surety Bond (8/15/2025). Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is current with an expiration date of 6/20/2025. Physical Plant/Environment Safety: 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. The facility has one (1) fully charged fire extinguisher. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Facility has a fire pull-alarm in the dining area and heat detectors. Cleaning supplies, knives, and toxic substances were observed unlocked/accessible to residents above the washer/laundry area. Discarded furniture was observed outside the north side of the home, and bathroom #2 had mold on tile and shower mat. Staffing: A total of 8 staff members provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expired 7/10/2024; pending approval from CCL Recertification Unit. Staff have criminal background clearance and training. Five (5) staff files were reviewed. Proof of staff training, health and TB clearance, and 1st Aid/CPR training are on file. ****Report narrative continues next page.***** Resident Records/Incident Reports: Four (4) resident files were reviewed. They contained admission agreements, IPPs, Behavior Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent. Centrally stored medication records are in place. RCFE complaint poster and Personal rights were observed posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. 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. One resident has a modified diet plan. Incident Medical and Dental: Four (4) centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by facility staff. An error on resident (R1's) Medication Administration Record was observed. It stated that medication Levothryroxine 50 MCG is to be administered at 5 PM, but it should be medication Levetiracetam 500 mg. Staff are putting their initials on the wrong medication line. A citation was issued. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 10/5/2024. Residents with Special Health Needs: No residents are receiving hospice services or home health services. Resident (R1) has a restricted health care plan on file. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Assistant Administrator Danielle Maximo. A copy of the report and appeal rights was issued.