Routine inspection (multi-day)·January 23, 2025

At approximately 9:00AM, Licensing Program Analysts (LPAs) Felias and Magdaleno arrived unannounced to continue a Required 1 Year Visit and met with Business Office Director, Ditter Vasquez, and Wellness Nurse, Remy Fairbairn. Executive Director, Kimberly Humphrey, arrived during visit at approximately 12:30PM . Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 70 non-ambulatory and bedridden residents. Of the 70 residents, 20 residents can be bedridden. Facility has an approved hospice waiver for 16 individuals. Facility is currently on a Non-Compliance Plan. Upon arrival, LPAs were informed that there were 47 residents in care and 19 staff members on-site. LPAs reviewed Facility Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPAs reviewed staff and resident files and resident medication. During staff file review, LPAs observed that 5 of 6 staff members did not have current First Aid certification, and 3 of 6 staff members did not have CPR certification (deficiency cited, LIC809D, Health and Safety Code 11569.618(c)(3)). During resident file review, LPAs observed that 1 of 5 residents did not have an updated Physician's Report as required (technical violation issued, LIC9102, regulation 87463(h)). Medication was found to be centrally stored and secure. As part of their Non-Compliance Plan, LPAs also requested and reviewed documents for all employees hired from November 2024 to January 2025. Review of documents showed that facility hired 5 individuals during this time frame. Document review showed that facility has conducted training or have scheduled training for them in the following areas: Reporting Requirements Personal Rights Incidental, Medical, and Dental Care Welfare and Institutions Code Administrator and Designated Representatives LPAs followed up on incident reports that were submitted to Community Care Licensing (CCL): Continued on LIC809C Continued from LIC809 Incident Report 1/SOC341 : CCL received an incident report and SOC341 on 12/02/2024. Reports state that on 11/25/2024, Staff Member 1 (S1) observed Staff Member 2 (S2) taking Resident 1's (R1) medication card from the facility medication cart. Per reports, S2 also took two Tylenol tablets from R1's medication bottle. Facility conducted an internal investigation and medication audit and found that 42 tablets were missing from R1's medication. Reports stated that facility conducted an in-service training. Facility made all appropriate notifications per regulation. Executive Director informed LPAs that S2 has since been terminated and is no longer working at facility. LPAs obtained copy of in-service training. Incident Report 2 : CCL received an incident report on 01/23/2025. Report states that on 01/15/2025, Staff Member 3 (S3) observed that Staff Member 4 (S4) did not give Resident 2 (R2) their medication as prescribed on 01/14/2025. Additional documentation showed that R2's medication was documented as given. S2 notified management and a medication audit was conducted (deficiency cited, LIC809D, regulation 87465(a)(4)). Report stated that S4 was suspended pending internal investigation and that facility would receive in-service training. Facility made all appropriate notifications per regulation. Executive Director informed LPAs that S4 has seen been terminated and is no longer working at facility. LPAs reviewed Facility's Guardian Roster and confirmed that S2 and S4 have been removed from the facility and are no longer working on-site. LPAs requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Updated Liability Insurance Active and Current Administrator Certificate Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on form confirms receipt of documents.