Routine inspection·November 22, 2024

Licensing Program Analyst (LPA) Reyes conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with with Licensee Rey John Bertulfo and Administrator Ivy Bertuifo and explained the reason for the visit. The facility is licensed for an age range 60 and over. Fire clearance approved for six (6) non-ambulatories where four (4) can be bedridden in room #5,6,7 and 8. Room #3 and #4 is for non-ambulatory only. Waiver/granted for hospice care for six (6) residents. Dementia and bedridden plan submitted. Administrator Ivy’s Residential Care for the Elderly (RCFE) certificate for administration expires 2/16/25. LPA obtained a current copy of the Certificate of Liability Insurance for Excellence Board and Care LLC. Licensee Rey did not have any documents supporting an Emergency Disaster Drill was completed. Facility is a single-story home located in a residential area off of a main street consisting of eight (8) bedrooms; 6 private resident bedrooms and 2 staff bedrooms, 10 bathrooms, kitchen, dining room, living room, two (2) covered fireplaces (1 electrical fireplace & 1 gas), laundry room, large backyard outdoor covered patio, storage structure in the rear, and attached garage. Front and back yards are landscaped with grass. Total of 10 bathrooms, one (1) half bath and 9 full bathrooms with working toilets, wash basins, and walk-in showers, with the exception of room #2, which has a large bathtub. The one (1) half bath in the kitchen water temperature measured at 71.4 degrees f, restroom #4 water temperature measured at 86.7 degrees f., and restroom #9 outside water temperature measured below the 105 degrees f. The water temperature in three (3) restrooms did not meet Title 22 regulations, which require a range of 105 – 120 degrees f. LPA observed cleaning products stored inside a kitchen cabinet underneath the sink accessible to residents. The cabinet did not have a lock or other safety mechanism in place to prevent access. Cleaning products included (2) powder cleanser (Bar Keepers Friend). Located in the kitchen island cabinet were (2) cleaning sprays Weiman Stainless Steel and an unidentified cleaning solution. The cabinet did not have a lock or safety mechanism. Stored in the pantry cabinet unlocked and accessible to residents was a can of butane fuel (First Street brand). In the unlock laundry area was (2) Clorox and (1) detergent bottle. Appliances: Refrigerator, oven, microwave, dishwasher and washer/dryer are in working condition. The residence is equipped with central heating and air conditioning --Continued LIC809-C-- LPA observed a box cutter with blade attached and scissors in an unlocked drawer in the office area. The tool and scissors were accessible and not secured. LPA observed in the office area a filing cabinet ajar and unlocked contents were residents and staff medication. In staff room #1 the door was unlocked and medication was present and accessible to residents. Located in the dresser in the dining room was a (1) bubble pack of pills Hydroxyzine HCL 25 MG in the drawer. LPA observed a closet door in resident #1 (R1) room was inoperable. The issue appeared to be caused by significant rust damage to the door track, preventing proper opening and closing. LPA observed resident #1 (R1) with full bed rails and R2 with half bed rails. R1 is not receiving hospice care. Licensee does not a have a note from R2's physician for half bed rails. In R2’s closet and on top over the dresser in a small box was eye drops. Per R2's Physican Report R2 is unable to “administer and store own medications”. Smoke Detectors: There are electrical & inter-connected smoke detectors located in all bedrooms, common areas, and hallways Linens & Hygiene Supplies: All beds had the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linens is stored in hallway closets. During review of R1 and R2's medication for the November 2024 facility has not been documenting each does of medication administer or missed by residents. When LPA requested the November 2024 medication sheet for R1 Licensee Rey and Administrator Ivy was only able to provide an August 2024 medication sheet with no staff initials. The medication sheet that was provided for R2 was missing the month label and staff initials. It was observed for R1 that medication was not being given as prescribed by a physician. R1's PM Medication- Temazepam 15 mg QTY 30 (Take 1 capsule by mouth at bedtime) was full despite date being filled on 9/23/24. R1's PM Medication- Temazepam 15 mg QTY 30 (Take 1 capsule by mouth at bedtime) had twenty-eight (28) pills despite being filled on 1111/24. This revealed that facility had two of the same medication Temazepam 15 mg QTY 30 and was not being given. --Continued LIC809-C-- It was observed that R2's medication was not being given as prescribed by a physician. R2's AM Medication - Eliquis 2.5 MG (Take 1 tablet by mouth every morning and evening) twenty-three (23) pills had been administered for November 22, 2024. R2's AM Medication- Senna Plus 50-8,6 MG (Take two tablets by mouth every morning and evening) November 6, 2024 medication was not administered no supporting documents was provided no supporting documents was provided for reason. R2's AM Medication - Risperidone 0.5 MG ( Take 1 tablet by mouth every morning and evening) November 4th - November 11th 2024 medication was not administered no supporting documents was provided for the reason. R2's Evening Medication - Senna Plus 50-8,6 MG (Take two tablets by mouth every morning and evening) November 5, 6, 10, and 16th medication was not administered no supporting documents was provided for the reason. LPA observed in the backyard outside the shed a mattress, shopping cart, television, two (2) dressers, and an unhinged door. On the side of the shed was broken pieces of tile. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided