Follow-up on corrections·November 7, 2023

Licensing Program Analyst (LPA) Alviso conducted a case management visit, on 11/7/23 at approximately 11:23am, and met with Rosita O'Campo, Lead Caregiver. LPA observed another caregiver, Zenaida Narciso, on duty during the inspection. LPA observed a large container of several prescribed medications, as well as over the counter medications out in the open, not locked up, stored in the corner right side of the common area on the lower level. LPA obtained pictures. This deficiency will be cited, 87465(h)(2) Incidental Medical and Dental Care -Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, see LIC809D. LPA observed there are three (3) residents on the upper level, two (2) residents have/use walkers, and one (1) resident is wheelchair bound. LPA observed the inside upper-level stairway entry is open and accessible to residents who are non-ambulatory, there is no barrier for residents’ safety, this is a health and safety hazard to residents in care. LPA observed that the upper-level sliding door leads out to a balcony which at the end of the balcony are steep stairs with no barrier for residents safety, this is a health and safety hazard, deficiency will be cited, Personal Accommodations and Services (d)(4)-The following space and safety provisions shall apply to all facilities: Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents, see LIC809D. LPA observed the facility does not have fire/emergency exits per LPA's inspection, the facility only has stairs inside on the upper floor and outside stairs from the balcony, this is a health and safety hazard to residents in care. This deficiency will be cited, H&S Code Emergency Plans 1569.695 (a)(d) (1)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. An evacuation chair at each stairwell, see LIC809D. Licensee to ensure that all deficiencies are corrected in a timely manner, and all plans of corrections are submitted by due dates, see LIC809Ds. Continued on LIC809C... The Department has contacted the State Fire Department, Fire Department for outside of Napa city limits, regarding information on fire clearance approval; The Department requested information from State Fire Department on fire code requirements for non-ambulatory on a second floor, and required emergency fire exits on a second floor. Emergency and disaster plan, LIC610E, must be reviewed, updated, signed/dated, and submitted to the licensing Department, regarding current residents in care and facility emergency evacuations, including facility having evacuation chairs. This plan is due no later than 11/17/23. All staff must be trained in the updated emergency disaster plan; Staff to be trained in instructions on use of the evacuation chair, ensure staff know how to operate it. Staff are to be trained in the facility policy and procedures, regarding the two sturdy barrier gates. Licensee agreed to install the barrier gates, one at the top of the inside stairs, and one outside at the top of the balcony. Proof of training due by 11/30/23. Include trainer, topics, date/time spent, and attendees. Licensee has agreed to ensure secure sturdy barriers/gates are installed, one inside the facility at the top of the stairs on the second level, and on the outside second level balcony at the top of the stairs.. All staff are to be trained in the policy and use, 24/7, of the gates being kept closed at all times. This must be installed and completed no later than 11/30/23. Licensee has agreed to submit a plan on ensuring sufficient staffing to supervise residents at all times in regard to the stairs inside the facility and the stairs outside off the balcony that currently don't have barriers for residents safety. You will ensure all residents are supervised as needed, 24/7, to ensure health and safety regarding these stair openings, until both the stairs have barriers as required. Residents have the right to access the facility common areas, the Licensee is to ensure sufficient staffing as to not restrict residents' use of the common areas. Please submit this plan including the above no later than 11/9/23. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited, see LIC809D pages. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator Norbert Sacro. Appeal Rights provided.