Routine inspection·October 19, 2023

License Program Analyst (LPA’s) Hansen and Rummonds arrived unannounced to conduct an Annual Required – 1 yr. visit of the facility. LPA’s had caregiver Josefa Mancinas contact Administrator who arrived during the inspection. There is a total of 22 residents. There is 2 residents currently on Hospice and some residents with Dementia. LPA’s entered the facility with auditory alarm going off and waited in entrance room for approximately 7 minutes observing other residents walking the halls and then went to find care staff, all of which were in dining area (see LIC809-D) LPA’s toured the facility on 10/19/2023 at 9:15 AM with Josefa Mancinas; 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 6/29/2023 at the time of the visit. Facility smoke detectors were tested and found to be operational at the time of the visit. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 10/5/2023 . LPAs observed Carbon monoxide detectors that were found to be operational during the visit. There is a backup generator that powers many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 110.4 degrees F and 100.4 degrees F. falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 6 of 9 resident’s bathrooms while touring facility on 10/19/2023 at 10:25AM (see LIC809-D). Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPAs toured the kitchen area on 10/19/2023 at 10:00 AM; although toxins were observed stored with food in kitchen (see LIC809-D). Food is available for residents any time of the day. There is a daily activity schedule for residents. Continue on LIC809-C Toxins are stored in a locked housekeeping closet and under the kitchen cabinet; although LPA’s observed toxins in resident bathroom as well as razors. While touring outside LPA’s observed multiple cans of paint on back patio accessible to residents in care (see LIC809-D) There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in bathroom showers. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. LPAs observed a strong smell of urine in downstairs common bathroom & in resident (R1) bedroom on 10/19/2023 at 10:15AM (see LIC809-D). LPA’s also observed multiple bathrooms containing communal hand towels and bathrooms without paper towels (see LIC809-D). LPA’s and Administrator observed side door to facility with shattered/taped window (see LI809-D). A sample review of five resident & five staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 11:27AM on 10/19/2023 and learned that 5 of 5 residents have update reappraisal/needs & care plan on file at this time as required by Title 22 Regulation. Medications were centrally stored in a locked medication cabinet in the facility medication room. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 10/19/2023 at 2:00PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. LPAs conducted a sample reviewed of staff records at 12:37PM on 10/19/2023 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1 st Aid certification for all staff. Neysa Hinton, Administrator Certificate # 6053696740 expires on 10/30/2024. LPAs reviewed Licensing Information System (LIS) with Administrator who stated that is current 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 been conducted quarterly with the last one being conducted on 9/29/2023. Continue to LIC809-C Appeal Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided. LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 11/9/2023: Copy of Annual Sprinkler Inspection LIC 308 Designation of Responsibility LIC 309 Administrative Organization LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator’s Certificate Proof of Liability Insurance