Routine inspection·October 12, 2023

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. visit of the facility. LPA was welcomed by Administrator/Licensee Pilar. There is a total of 2 residents, none have a diagnostic of dementia and no residents currently on Hospice. LPA toured the facility on 10/12/2023 at 9:10 AM with Pilar - licensee; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 4/11/2023 at the time of the visit. Smoke detectors and carbon monoxide detector were found to be operational during the visit. Hot water temperature measured between 115 degrees F and 115.3 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 10/12/2023. The facility serves residents with dementia and has a plan of operation for special care and programming. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked hallway closet. The bathrooms designated for residents at the facility were supplied with hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 10/12/2023. A review of two resident & three staff records and licensee/administrator as well as two resident’s medications was conducted. LPA reviewed resident’s files at 10:00 AM on 10/12/2023 and learned that 2 of 2 residents have updated appraisals/needs & care plans and physician’s assessment (LIC 602A). Medications were centrally stored in locked cabinet in the facility kitchen area, although some were pre-poured (TV given). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 10/12/2023. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete. Continue LIC 809-C LPA reviewed a sample of staff records 10/12/2023 at 11:00 AM and learned that 1 of 4 facility staff (S1) who require caregiver background checks have not received a criminal record clearances or exemptions and have been working at facility since 9/1/2023 (see LIC809-D & LIC421BG for $500 Civil Penalties). Direct care staff has no proof of annual training requirements for 2022/2023 on file (see LIC809-D). Facility also did not have proof of 2 of 4 staff’s Health Screening or TB test (see LIC809-D). Facility was able to present LPA with proof of CPR for 4 out of 4 staff & 1 st Aid certifications for 4 out of 4 staff that files were reviewed. Maria Del Pilar de Olave Administrator Certification # 6030062740 expired on 12/7/2022 and has not renewed (see LIC809-D). LPA reviewed Licensing Information System (LIS) with licensee/administrator who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have not been conducted quarterly as required by Emergency and Preparedness Health & Safety Code. (see LIC 809-D) & or submitted required Infection Control Plan (LIC809-D) Civil Penalties of $500 given for staff working at facility without obtaining background clearance for over 1 month. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Continue on LIC 809-C LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 10/31/2023: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Certificate of Liability Insurance Copy of Administrator Certificate