Routine inspection·August 24, 2023

License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an Annual Required – 1 yr. visit of the facility. LPA was welcomed by staff June Gallen Mateo & Mariel De Vera. Ana De Ventura – Administrator/Licensee was contacted by staff and arrived during the visit. There is a total of 6 residents and 4 with a diagnostic of dementia. There are 2 residents currently on Hospice. LPA toured the facility on 8/24/2023 at 8:55 AM with staff June Gallen Mateo; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices; 4 out of 5 auditory devices were missing and one was falling down. Exiting could present a hazard should residents exit facility unattended (see LIC809-D). Fire Extinguisher was found to be last charged on 6/20/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 118.2 degrees F and 130.1 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 1 of 2 resident’s bathrooms while touring facility on 8/24/2023 at 9:10am (see LIC 809-D). The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. 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 the garage, however; garage knob lock is facing the kitchen and can be unlocked without any key or device and sharp scissors were left on counter & in unlocked kitchen drawer. Facility has 4 residents with a diagnostic of dementia. (see LIC 809-D) There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels and 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. Facility understands that resident’s beds must be outfitted with mattress pads as required by Title 22 Regulations # 87307 unless residents refuse - mattress pads must be available at the facility on 8/24/2023. Continue LIC 809-C A review of 5 resident & two staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 10:45 AM on 8/24/2023 and learned that 5 of 5 residents have an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A). Facility to ensure that approved Admissions Agreements are always posted and/or accessible to public view in the facility as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement , modifications and attachments, or notice of their availability from the facility.” Medications were centrally stored in locked cabinet in the facility living room area; although there was pre poured medications in unlocked kitchen drawer observed by LPA and staff (see pics) at 9:02 AM on 8/24/2023 (see LIC809-D). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 8/24/2023 at 11:45 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. LPA reviewed a sample of staff records at 12:45 PM on 8/24/2023 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2023 are on file. LPA was presented with proof of CPR & 1 st Aid certification for staff that files were reviewed. Ana De Ventura Administrator Certificate # 6027968740 expires on 9/23/2023. LPA reviewed Licensing Information System (LIS) with licensee/administrator who stated that is corrected and updated at this time; however facility will be changing mailing address, administrator will send in required documents (LIC200 etc..). 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 8/12/2023. Continue LIC 809-C 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. LPA Hansen is requesting Administrator to update and submit the following documents by 9/14/2023 to CCL: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurance Copy of Deed