Routine inspection·April 23, 2024

Licensing Program Analysts (LPAs) Cuadra and Rummonds made an unannounced required annual inspection of this facility and met with facility acting Administrator Erlinda Ferris. Annual fees current. LPAs/Administrator toured the building and grounds which was found to be clean and in good repair. The main building is two stories and currently there are seven residents residing upstairs. Second building is single story and currently there are two residents. At approximate 10am LPAs/Administrator did not observe assigned staff in the second building providing care and supervision to resident in care who has a non-ambulatory status as indicated in their facility plan of operation. Assigned staff was walking into the second building as we were touring the facility. LPAs reminded the Administrator the requirement to have an assigned staff at all times in the second building to assist residents in care. Administrator could not provide a reasonable explanation regarding the absence of assigned staff in the second building. Medication is centrally stored and locked in medication cart and closet. A sample of medication and medication records reviewed. Facility has cameras is both buildings in common areas. However, at approximate 10:05am LPAs/Administrator observed cameras located in private room #2 and 26. Per Administrator, resident's responsible parties brought the cameras without permission. LPAs/Administrator also smelled several bathrooms has a strong urine odor. LPAs/Administrator did not observe any CCL's reports placed in a conspicuous place. Also, the facility does not have required CCL complaint poster. A technical violation will be issued. At approximate 10:30am LPAs/Administrator observed hot water measurements of 129.3, 132, 145.2, 136 and 146.8 degrees which is not within regulation between 105 and 120 degrees F at faucets used by residents in care. Fire extinguishers inspected were charged and dated 4/5/2024. Smoke detectors were tested in resident rooms. Facility has fire sprinklers throughout. Carbon Monoxide detectors were present. The last disaster drill was conducted on September 27, 2023. Continued on LIC809C... Continued from LIC809... Residents have emergency pull cords in restrooms, call buttons at bed side and facility uses Wander Guard alert system. All auditory devices sound in the kitchen and light indicated alert in Administrator office. The amount of fresh and nonperishable foods is within regulation. LPA toured the kitchen and dinning areas. At 10:45 AM LPAs/Administrator observed expired canned goods, unpacked dry good not with expiration dates noted in the food pantry storage and unlocked laundry room with toxins and cleaning supplies accessible to residents in care. Also, LPAs/Administrator did not observe any auditory alarm on the second story door located in the main building, which leads to steep stairs. Hoyer lift used for residents in care was tested and it was found operational during the visit. However, staff observed might receive additional training to operate this type of equipment. A discussion with Administrator was handled to explain the importance of staff having better knowledge in how to operate the hoyer lift equipment properly. LPAs initiated file review at 11am. Five residents and five staff files were reviewed. Four out of five staff (S1, S2, S3 and S4) did not have a current CPR/1st aid on file. Two out of five staff (S1 and S2) do not have a health screening including TB test on file. Five out of five staff (S!, S2, S3, S4 & S5)do not have required annual training hours completed on file. Five out five residents (R1, R2, R3, R4 & R5) who has a diagnosis of dementia need an updated medical assessment and care plan. Several residents have half bed rails, but they do not have a doctor's order on file for use of half bed rails. Per Administrator, they had been working with resident's physician to obtain one for each of them. Administrator certificate for administrator Erlinda Ferris 6054488740 expires on 12/8/25. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this inspection: LIC500- Personnel Report. LIC308- Designation of Responsibility. LIC610E- Disaster Plan. Evidence of Liability Insurance. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given. Exit interview was conducted with Administrative assistant who was informed that the Department will be reviewing if further action is needed to address the overall compliance of the facility and a copy of this report was given.