Post-licensing visit·May 7, 2024

Licensing Program Analyst (LPA) Shannan Hansen arrived announced to conduct a Post-Licensing Inspection and met with Administrator, David Cervantes-Vibat. There are 5 residents at facility with 2 having dementia diagnosis, none on hospice. Facility tour/inspection began at 9:25 AM: LPA toured the facility on 5/7/2024; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility has special care plan of operation and programming for residents with dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. Food is available for residents any time of the day. Cleaning supplies and toxins are locked in closet in the hallway and garage. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms at the facility were supplied with paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom showers. Hot water temperature measured within Title 22 acceptable regulation of 105 to 120 degrees in bathroom faucets accessible to residents in care. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Fire Extinguisher was found to be last charged on 7/28/2023. Smoke detectors and Carbon monoxide detectors were tested and found to be operational. Facility has areas inside and outside for visiting and activities. File Review began at 10:45 AM: A sample review of five residents & five staff records as well as two resident’s medications was conducted. LPA learned that 5 out of 5 residents have updated reappraisal/needs & care plan as well as medical assessments. Continue LIC 809-C A review of five staff records show, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements; LPA was also provided required proof of CPR & 1 st Aid certification. Medication Audit began at 1:20 PM: Medications were centrally stored in locked hallway closet although during tour LPA observed medications in unlocked kitchen drawer (see pic & LIC809-D). LPA observed medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to have all medications entered for residents. LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Facility has supplies enough to operate for more than 72 hours in an emergency. Disaster Drills are to be conducted quarterly and in different shifts (see LIC9102). In addition, David Cervantes-Vibat, Administrator Certificate # 6067669740 expires 10/11/2025. 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 Licensee to update and submit the following documents by 5/30/2024 to CCL: LIC 308 Designated LIC 500 Personnel Summary LIC 9020 Register of Facility Resident’s Proof of Liability Insurance Control of Property/Lease