Routine inspection·December 12, 2023

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required - 1 yr. visit of the facility. LPA met with Administrator, Angelina Simi for today’s visit. There is a total of 5 residents, 4 with a diagnostic of dementia. There is 2 residents currently on Hospice. LPA toured the facility on 12/12/2023 at 10:50 AM with administrator Angelina Simi; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility serves residents with dementia and has a plan of operation for special care and programming. All bedrooms have lighting & appropriate furnishings. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry area, although cleaning detergents (Clorox bleach, spray & wipes) were found underneath both unlocked resident bathroom sinks at 10:55 am (see LIC809-D) Administrator removed items immediately. Hot water temperature measured 102.3 degrees F and 126.5 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 12/12/2023, (see LI809-D). Administrator informed facility just had pluming work that might not have fully corrected problem and scheduled follow up with plumber today. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. Fire Extinguisher was found to be last charged on 9/15/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. A review of 5 residents & 3 staff records as well as two resident’s medications was conducted during this visit. LPA reviewed resident’s files at 12:15 PM on 12/12/2023 and learned that 5 of 5 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A) on file. Continue LIC 809-C At approximately 1:15 PM LPA reviewed a sample of staff records and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff files have proof of annual training requirements on file. LPA was presented with proof of CPR & 1 st Aid certification for staff that files were reviewed. Medications were centrally stored in locked cabinet in the facility kitchen area. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 12/12/2023 at 2:00PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be completed and accurate. LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; only need to update email & add Admin.’s mobile. 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 are conducted quarterly with the latest on 9/15/2023. Angelina Simi Administrator Certificate # 6056410740 expires on 6/14/2024. 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 facility to submit the following documents to CCL by 1/15/2024: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Current Administrators Certificate Copy of Control of Property/New updated Lease Copy of Certificate of Liability Insurance