Post-licensing visit·June 17, 2022

This is an amended report. On 06/17/2022, Licensing Program Analyst (LPA) A. Walton arrived unannounced to conduct a Post-Licensing Inspection. LPA introduced self, stated that purpose of the visit and was granted entry to the facility. LPA met with Assistant Administrator, Denise Ordonez and Administrator, Jessica Johnson. Facility currently has 3 residents in care. LPA conducted a tour inside and outside the facility with Administrator. Facility observed to be clean, odor free, and at a comfortable temperature. The dining room and living room were furnished well with adequate seating and lighting. Resident rooms appeared clean and had all required furnishings. 1 bedroom is single occupant, the second resident bedroom is shared, beds were observed to be at least 6 feet apart. LPA observed an adequate supply of linen. Facility has an adequate supply of PPE and cleaning supplies. Resident bathrooms were properly equipped with securely fastened grab bars and non-skid mats. Bathrooms were stocked with liquid soap and paper towels. Hand-washing signs observed by bathroom sinks. Hot water in 3 bathrooms measured between 109.3 - 119.3 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable foods. Facility did not have a 2-day supply of perishable food. Knives/Sharps observed to be locked in the medication cabinet. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching. Fire extinguisher serviced on 03/21/2022. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Facility has not conducted a fire drill as of this date. All chemicals observed to be locked and secure laundry room. Medications observed to be locked in a cabinet in the kitchen. LPA reviewed resident records and medications. Review of medications revealed that R1 has not received R1's medication of Sertraline HCL 50MG for the past 8 days. MARs observed to be signed off as given. LPA observed that R2 is missing 2 PRN medications, Acetaminophen and Hyosclamine. LPA reviewed personnel files for first aid and criminal record clearance. Administrator has been unable to provide documentation for proof of staff training. Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted with Administrator. A Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Jessica Johnson, whose signature on this form confirms receiving this document.