Routine inspection·October 23, 2023

Licensing Program Analyst (LPA) Alviso, conduct a Required- 1 Year inspection and met with Administrator Edwardson Manalo. There are currently two (2) residents on hospice care. Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has an approved hospice waiver for residents in care as needed. There is an approved plan of dementia care. Fire clearance is approved for six (6) non-ambulatory. The LPA reviewed four (4) client files. The LPA reviewed six (6) staff files. All staff had criminal record clearance as required. LPA toured the facility with Administrator. Hot water was checked 112.8 Fahrenheit. LPA observed all exits to be free of obstructions. Fire extinguisher is tagged and serviced as required. Napa Fire Department came out and inspected the fire alarm system, passed inspection, 8/8/2023. Facility's smoke alarms are also carbon monoxide detector; There are also two separate smoke alarms. Food supply was observed to be sufficient. The facility was clean and orderly. Facility had a sufficient supply of hygiene products, cleaners, and paper products. Facility had a sufficient supply of personal protective equipment (PPE). Bathrooms had roll in showers, grab bars, and mats for resident use. Facility had night lights for resident use as needed. LPA observed a 72 hour shelter in place supply, which is required. Licensee/Administrator to submit the following documents by 11/23/23: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 9020 Register of Residents LIC 610 E Emergency Disaster Plan for RCFE -reviewed & updated as needed Copy of current Liability Insurance Infection Control Plan-reviewed & updated as needed LIC400 Handling of Client Cash Resources, include copy of surety bond. Continued on LIC809C... The following deficiencies were cited: Based on LPA's file review, there were no documented records of facility's quarterly emergency drills. This will be cited, H&S Code 1569.695 ( c) a facility shall conduct a drill at least quarterly for each shift. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill, see LIC809D. Based on LPA's file review, Three (3) out of five (5) staff did not have a completed health screening report, including a TB test and results.This deficiency will be cited, 87411 (f) Personnel Requirements - General-all personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure, see LIC809D. Based on LPA’s file review, S1 didn’t have an annual medical assessment which is required, this will be cited, Care of Persons with Dementia 87705 (c ) (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs, 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. Exit interview conducted with the Licensee/Administrator Edwardson Manalo. Appeal rights provided to the Administrator Edwardson Manalo.