Routine inspection·December 27, 2023

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required - 1 yr. visit of the facility. LPA was welcomed by staff Josefina Harris who contacted Administrator, Minerva Villegas for today’s visit. Current Administrator Villegas and soon to be Administrator Shanti Subba Pickett arrived during the inspection. There is a total of 19 residents, 14 with a diagnostic of dementia. There is 8 residents currently on Hospice. LPA toured the facility on 12/27/2023 at 8:50 AM with staff; facility was found to be clean and in good repair at a comfortable temperature with all exits free from obstruction. Exit alarms were working properly. Facility serves residents with dementia and has a plan of operation for special care and programming. All bedrooms inspected have lighting & appropriate furnishings. LPA observed residents were participating in an exercise activity. 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 were locked and secured. Facility has extra fresh linens and hygiene supplies available for residents. Hot water temperature measured 110.1, 118.7, 122.3, 123, 129.7, 137.8 & 140.5 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 5 resident’s bathrooms & the 2 shower rooms while touring facility on 12/27/2023, (see LIC809-D). Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. Facility has smoke detectors and sprinkler system. Fire panel was last inspected 10/26/2023. Fire Extinguisher was found to be last charged on 7/26/2023 at the time of the visit. Carbon monoxide detectors were found to be operational during the visit. A review of 5 residents & 5 staff records as well as resident’s medications was conducted during this visit. LPA reviewed resident’s files at 11:15 AM on 12/27/2023 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; although 2 of 4 care staff (S1 & S2) files reviewed did not have current 1 st Aid certification (see LI809-D). Medications inspected were in their original containers. Facility has a written medication administration record (MAR) and provided a copy of their last medication audit conducted by an outside agency dated 10/20/2023 stating the facility was found in compliance with medication storage, first aid kit, medication centrally stored, destruction records including medication refrigerator storage and controlled narcotics. LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time, although there is a new Administrator change. 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 only been conducted once to twice a year, with the latest 3/2023 (see LIC 809-D). Minerva Villegas Administrator Certificate # 6065970740 expires on 10/21/2025. 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. 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