Routine inspection·October 2, 2023

Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 10/2/23 at approximately 10:20am, and met with caregivers Angelina Manabat, and Romeo Manabat. Caregiver Angelina contacted the Administrator and notified them that the LPA was at the facility. The Administrator Charmaine Mendaros arrived within an hour of being notified that the LPA was at the facility. Facility has an infection control plan as required. Facility has an emergency and disaster plan as required. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Fire clearance is approved for one (1) ambulatory, and five (5) non-ambulatory, of which three (3) may be bedridden ; 1 bedridden in room #5, 2 bedridden in room #4, 1 non-ambulatory in room #2, 1 non-ambulatory in room #3, and 1 ambulatory in room #1. Fire extinguisher expires soon, one(1) scheduled to be serviced and tagged this Thursday,10/5/23. Facility was found to be clean, orderly,and at a comfortable temperature with all exits free from obstruction. Hot water was checked at 117.F which is within regulation. Medications were stored and locked making them inaccessible to residents. All toxins and cleaners were stored in locked cabinets, and inaccessible to residents in care. There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. LPA observed sufficient supply of food, perishable and non-perishable. The LPA reviewed five (5) resident files. LPA reviewed five(5) of five(5) staff files. All five (5) staff have criminal record clearance as required. Per record reviews, three (3) staff are associated as required. Continued on LIC809C LPA is requesting the following documents be updated and submitted by 11/2/2023: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required) Copy of LIC400 Handling of Client Cash Resources, complete form and submit Copy of Surety Bond (if handling resident cash) Copy of Current Liability Insurance Copy of current Administrator Certificate Per LPA's file reviews, staff lack current First Aid, S2, S3, and S4. This deficiency will be cited, Personal Requirements-General 87411(c )1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross, see LIC809D. Per LPA's file reviews, direct care staff lack current CPR certification as required, S2, S3, S4, and S5. This deficiency will be cited, H&S 1569.618(c)(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR, see LIC809D. Per LPA's file reviews, staff S4, and S5 are not associated to the facility as required. This deficiency will be cited, Criminal Record Clearance 87355(e)(3) Request a transfer of a criminal record clearance as specified in Section 87355(c), see LIC809D. Per LPA's file review, staff, S2, S3, S4, & S5, files were found to be incomplete. This deficiency will be cited, Personnel Records 87412(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain all required records, see LIC809D. Continued on LIC809C... Per LPA's file review, staff, S2, S3, S4, and S5, have proof of required 40/20 hrs of required annual training. This deficiency will be cited, H&S 1569.625(b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training initially, and 20 hours annually, see LIC09D. Per LPA's review of files, staff S2, S3, S4, and S5 lack medication training as required, his deficiency will be cited, Personnel Records/Staff Training -1569.69(a)(2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment, see LIC809D. Deficiencies 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 being assessed. Exit interview conducted with the Administrator Charmaine Mendaros. Appeal rights were provided.