Routine inspection·October 28, 2024

On 10/28/2024 at 11:20 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. At the time of the visit there was one (1) staff present, and two (2) residents present. Administrator Brandon Marquez and Licensee Sandy Zhao was contacted and informed of the visit. Administrator Marquez was not at the facility during the visit. LPA Brown explained the purpose of the visit to staff Sahian Suarez Camacho.. The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room, activity room and laundry area. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory. The facility has six (6) Hospice Waiver. The current census is two (2) residents. LPA Brown was accompanied by staff Camacho to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant : The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). The facility is equipped with operating smoke detectors but LPA Brown observed no carbon monoxide at the facility. Deficiency will be issued. LPA Brown observed no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 107 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as mattresses and storage space, however, LPA Brown observed missing one (1) chair and one (1) lamp in resident #1 (R1) and resident #2 (R2) bedroom. Technical Violation issued. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and the customized bathroom tiles in the resident bathrooms. ***Continuation in LIC809C *** Also, LPA Brown observed Resident #2 (R2) with full bed rails and Staff #2 S2) reported to LPA Brown that R2 is not on Hospice Care and no written order from R2 physician was observed indicating the need for postural support/full bed rail. LPA Brown observed no exception letter submitted and approved by Community Care Licensing Division (CCLD) for R2's full bed rails. Deficiency will be issued. In addition, LPA Brown observed no night lights maintained in hallways and passages to non-private bathrooms. Deficiency will be issued. Furthermore, during the tour of the facility, LPA Brown observed one (1) scissor, four antibiotic ointments in R1 and R2 bedroom, not locked and accessible to residents in care. Also, LPA Brown observed two (2) gallons of bleach, three (3) bottles of cleaning solutions, one bottle of laundry detergent in the garage, not locked and accessible to residents in care and one (1) scissor in the hallway closet, not locked and accessible to residents in care. Deficiency will be issued. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the medication cabinet. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. However, LPA Brown observed the facility's auditory device to alert staff to monitor exits is in disrepair. Deficiency will be issued. Food Service : Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. Care & Supervision : LPA Brown observed no administrator present at the facility during normal working hours. Deficiency will be issued. Also, LPA Brown observed one (1) staff working at the facility and per staff interview and records review, no staff's scheduled to work the night shift, awake and on duty as required for facility with dementia residents. Deficiency will be issued.. ***Continuation in LIC809C *** ***This is an amendment copy of the form LIC809C issued today, 10/28/2024*** Record Review : LPA Brown observed Infection Control Plan maintained at the facility. However, LPA Brown observed the liability insurance maintained at the facility is for Worker's Compensation and Employers' Liability and it does not cover injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three (3) million dollars ($3,000,000) in the total annual aggregate caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. Deficiency will be issued. Licensee updated the required liability insurance during the visit today, 10/28/2024 and provided LPA Brown a copy. LPA Brown observed no fire and earthquake drill conducted at the facility. Deficiency will be issued. LPA Brown observed that the facility did not review the emergency disaster plan annually as evidenced of the Licensee/Administrator did not sign the emergency disaster plan this year. Deficiency will be issued. LPA reviewed two (2) resident files for admission agreements, updated physician reports, Pre-placement Appraisals, Centrally Stored Medication List, Preplacement Needs and Services Plan. LPA Brown observed Resident #2 (R2) physician report does not have physician signature and signature date and per documents review, R2 was admitted to the facility on 03/29/2023. Deficiency will be issued. LPA Brown observed Resident #2 (2) Physician Assessment indicated dementia but R2 does not have the required annual medical assessment for residents with dementia. Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results and LPA Brown observed Staff #2 (S2) First Aid/CPR certification expired on 10/22/2024. Deficiency will be issued. During medication audit, LPA Brown observed that facility staff did not assist Resident #1 (R1) with one (1) medication. Deficiency will be issued. Also, LPA Brown observed Resident #2 (R2) with one (1) medication without R2's physician authorization. Deficiency will be issued. Per records review, the facility was cited for the same regulations within 12-month period for CCR 87309(a), CCR 87458(a) and HSC 1569.618(a). Civil penalty will be issued today, 10/28/2024 with the amount of $250.00 per repeat violation within 12-month period. An exit interview was conducted where this report (LIC809), LIC809D, LIC421FC, LIC9102TV and LIC9102TA and Appeal Rights were discussed and provided to Sahian Suarez Camacho.