Routine inspection·April 11, 2024

At approximately 8:30 AM, Licensing Program Analyst (LPA) Shannan Hansen made an unannounced annual required inspection of this licensed senior care facility. LPA met with Licensee/Administrator Leni Stayman & House Manager Anna Marshall. There are 5 residents, all having diagnosis of dementia, with 4 on Hospice, At approximately 8:40AM, LPA toured the building and grounds with House Manager which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area; although when touring bedrooms room 2 resident uses oxygen and door did not have notice. Staff put sign on door during visit. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closets although during today's inspection LPA observed tool supplies and toxins/ WD-40 in unlocked hallway closet accessible to residents in care, staff replaced lock during visit (see pic & LIC809-D). Water temperature measured 112.4 degrees F. and 113.3 degrees F, within regulation of between 105 and 120 degrees F at faucets accessible to residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. Fire extinguishers were last charged 4/3/2024. Smoke and Carbon Monoxide detectors are one unit throughout facility and were found to be in working order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure, although at 9:25am on 4/11/2024 LPA observed pre-poured medication for AM and dinner in covered container in kitchen locked cabinet (see LIC809-D). During tour of grounds of facility LPA & Licensee observed construction of front yard by gardener that contained half cut wine barrel full of water that was to flow around the front in a trench that was dug. Licensee informed they didn’t know and had other gardeners/maintence workers dump water during visit and assured LPA there will not be any standing water in containers accessible to dementia residents in care. Also observed was a side fence (see pics) falling over (see LIC 9102 TV) Licensee will send pictures of proof fence has been fixed). Continue on LIC809-C Also observed back gates not containing locks to back property that contained paint cans, gas cans, sharp gardening tools, & sheds without locks containing 2, 5 gallon drums of paint (see pics). Licensee had all items put in sheds and put locks on all fences & sheds during visit. At approximately 10:15AM, LPA reviewed 5 of 5 resident records. 5 of 5 records contained current and signed admission agreements and physician's orders on file. Medication records are thorough and contained physician's orders for each resident; although resident (R1) records did not contain TB test (see LIC 809-D) House mgr arranged hospice to conduct test at next visit. Hospice care plans were up to date for each hospice resident. At approximately 11:00 AM, LPA reviewed 5 of 5 staff records. Evidence of current first aid for 4 of 5 staff were present ; although staff (S1) did not have proof (see LIC 809-D), CPR trainings were current. All other required training were documented and current. Required Health Screening (LIC503) was also missing for staff S1 (see LIC 809-D). The Medications of 1 out of 1 resident were found to be given according to physicians’ directions on 4/11/2024 at approximately 1:30 PM. Centrally Stored Medication Record (CSMR) of 1 out of 1 residents were found to be not complete and accurate not containing start dates. At approximately 12:30 PM, LPA reviewed the facility emergency disaster plan with staff. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts quarterly disaster drills with the last disaster drill conducted on 4/1/2024. Administrator certificate for Leni Stayman 6020433740 expires 10/09/2024. LPA reviewed Licensing Information System (LIS) with House Manager who stated that is correct and updated at this time; no need to change any of the information. 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 Continue on LIC809-C LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 5/3/2024: Some documents obtained at visit LIC 610 Emergency Disaster Plan (if changed) LIC 9020 Register of Facility /Resident’s Copy of Administrator’s Certificate