Routine inspection·January 31, 2024

Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Cynthia Garcia and was granted entry to the facility. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents, one (1) resident may be bedridden. The current census is six (6) residents. LPA was accompanied by Administrator to conduct a general overall inspection, which included, but was not limited to, the following: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to interior and exterior passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA found that the facility has two (2) residents (R3 and R6) in care with a condition that requires auditory alarms on exterior exit doors. The facility does not have auditory alarms on all the exterior exits. The facility will be issued a deficiency for not having auditory alarms on the facility exit doors. LPA measured and observed the water temperature in the bathrooms to be at 110.8 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. The non-perishable and perishable food supply is sufficient for the residents in care. During kitchen tour, LPA found cleaning supplies, toxins, and sharps were not kept inaccessible to residents in care. LPA found bleach in an unlocked cabinet underneath the kitchen sink, found knives in a knife container on the kitchen counter, and found knives in an unlocked drawer in the kitchen. The facility will be issued deficiencies for not properly locking the chemicals and for not properly locking the knives. During the kitchen tour, LPA found a plastic container that contained Staff S5’s personally used syringes and needles. The facility will be issued a deficiency for not storing the syringes and needles in a proper bloodborne pathogen’s container. During kitchen tour, LPA also found a bottle of R4’s medication being stored on the kitchen counter. LPA also found that Residents R1, R2, R3, R4, R5, and R6 medications were in an unlocked cabinet in the hallway. The facility will be issued a deficiency for not properly locking the resident’s medications. LPA also found that Residents R1, R2, R3, R4, and R6 medications were removed from the originally received prescription containers and were being stored in plastic containers labeled AM and PM. The facility will be issued a deficiency for not storing the resident’s medications in the originally received prescription containers. During the visit, LPA was informed by Staff S5 that Staff S5 administers injections for Resident R1 for a medical condition. The facility will be issued a deficiency for administering injections without being a properly skilled professional. During garage tour, LPA found that that facility created a sleeping area for Staff S4 that included a bed, a partition, and personal items. LPA found that the storage room in the garage had been converted into a bedroom for Staff S1 that included a bed and personal items. The facility will be issued a deficiency for creating sleeping arrangements in the garage and in the garage storage room. LPA found that the facility does not have sufficient care staff for coverage 24 hours a day, 7 days a week. The facility has two (2) resident’s that have a condition that requires an awake staff at night. LPA was informed by Staff S5 that the staff sleep at night and are on call if the residents need assistance. The facility will be issued a deficiency for not having proper staff to take care of the resident’s needs at night. The facility has designated storage space for resident files and staff files. LPA reviewed six (6) residents files for admission agreements, updated physician reports, and needs and services plans. LPA found that Residents R1, R2, R3, R4, R5, and R6 do not have needs and services plans. The facility will be issued a deficiency for not completing needs and services plans for the residents. LPA reviewed two (2) staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings. LPA found that Staff S5 and Staff S3 do not have First Aid/CPR certifications. LPA found that Staff S4 does not have a staff file and does not have a criminal record clearance to work at the facility. The facility will be issued a deficiency for not having First/Aid CPR certifications and for S4 not having a staff file. The facility will be issued a deficiency allowing Staff S4 to work at the facility since November of 2023 without a criminal record clearance. The facility will also be issued a civil penalty in the amount of $500 dollars allowing S4 to work at the facility without a criminal record clearance. Based on the observations made during today’s visit, thirteen (13) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations, along with a civil penalty. An exit interview was conducted, and this report (LIC809), LIC809D forms, LIC811, and LIC421BG were discussed and provided to with Administrator Cynthia Garcia, along with a copy of the appeal rights.