Routine inspection (multi-day)·February 28, 2024

Licensing Program Analyst (LPA) Shannan Hansen arrived at 10:30 AM to complete an unannounced annual inspection and was welcomed by staff Mary R. Staff called Supervisor Deirdre Villante who arrived shortly after. There is a total of 7 residents in care, no dementia and none on hospice. A review of seven residents & four staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 11:00AM on 2/28/2024 and learned that 7out of 7 residents do not have update reappraisal/needs & care plan on file at this time (see LIC809-D) and 1 out of 7 residents (R1) does not have a Physicians Report (602) as required by Title 22 Regulation (see LIC809-D). 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 2/28/2024 at 1:30 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate; although LPA advised during original inspection on 2/22/24 not to pre-pour medications, during today’s inspection facility had pre-poured medication again (see pics & see LIC809-D). LPA conducted a sample review of staff records at 12:00PM on 2/28/2024 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. Gary Piner, Administrator Certificate # 6012080740 is pending, payment was received 11/6/2023. Smoke detectors are hardwired into the fire system with fire sprinklers throughout. Fire Records indicate last inspection was conducted 3/2023. Continue to LIC809-C LPA reviewed Licensing Information System (LIS) with Supervisor 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 not been conducted quarterly with the last one being conducted prior to 7/2023 (see LIC809-D). 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 3/15/2024: 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 Control of Property Lease/Grant Deed Copy of Administrator’s Certificate Proof of Liability Insurance