Routine inspection·February 24, 2025

On 02/24/2025 at 9:00 AM, Licensing Program Analysts (LPA) Beena Singh and LPA Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with Administrator Ariel Angeles and was granted entry to the facility. At the time of the visit there were two (2) staff present, and four ( 4) residents present. LPAs Singh and LPA Brown explained the purpose of the visit to Administrator Ariel Angeles. The facility has 4 bedrooms, in which 3 bedrooms are designated for residents, and 1 bedroom is designated for staff, 2 bathrooms, living room, kitchen, dining area, backyard, and attached garage. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for a capacity of six (6) non-ambulatory residents, one (1) residents may be bedridden. The current census is four (4) residents. The facility has approved hospice waiver for six (6) residents. LPAs Singh and Brown were accompanied by Administrator Ariel Angeles 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 buildings and grounds were free from hazards. Outdoor and indoor passageways were kept free of obstruction. The facility is maintained at a comfortable temperature. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. Although there were no night lights leading to Non-private bathrooms, deficiency will be issued. bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. In addition LPAs observed Resident #2 (R2), Resident #3 (R3) and Resident #4 (R4) have half bed rail and per records review, R2 R3 and R4 do not have a written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued. ***Continuation in LIC809C*** ***This is an amended report of LIC 809 Facility evaluation Report issued on 02/24/2025*** LPAs Singh and Brown observed that additional room was added in the garage area with window, air conditioner, lights and full bathroom but per records review no letter was submitted to CCLD for the alteration made and no permit was obtained from city permit building department. Deficiency will be issued. LPA Singh measured and observed the water temperature in the residents bathroom to be at 115 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Postings such as the facility license, personal rights, the CCLD complaint poster, ombudsman poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were not locked and accessible to residents in care. Deficiency will be issued. In addition, LPAs Singh and Brown observed the facility not having the required first aid book/manual maintained at the facility. Deficiency will be issued There was a designated storage space for resident/staff files. Medications are kept inside the medication cabinet, however, LPAs Singh and Brown observed centrally stored medications are not locked. Deficiency will be issued. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service : Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility. Although, there is no emergency supplies, water and food. Deficiency will be issued. Care & Supervision : Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. ***Continuation in LIC 809C*** Record Review : LPAs Singh and LPA Brown reviewed two (2) resident file for admission agreement, updated physician report, centrally stored medication list and needs and services plan. LPAs observed Resident#1(R#1) does not have the required pre-placement appraisal maintained in R#1 file. Deficiency will be issued. LPAs observed residents#4(R#4) does not have the record needs and services plan/care plan maintained in R#4 file. Deficiency will be issued. LPAs observed residents#4(R#4) does not have the record needs and services plan/care plan maintained in R#4 file. Deficiency will be issued. LPAs reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings with tuberculosis (TB) test results. LPAs observed staff#2 (S#2) working at the facility with a criminal background clearance but S2 criminal background clearance was not transferred to the facility. Deficiency will be issued and civil penalty of $500.00 will be assessed today and will continue to be assessed of $100 per day until corrected. LPAs observed Staff#2(St#2) and Staff#3(S#) do not have the required on the job training maintained in their facility file. Deficiency will be issued. LPAs observed Staff#2 and Staff#3 do not have the required Tuberculosis(TB) test with TB test result maintained in their facility file. Deficiency will be issued. LPAs observed that Staff#2 and Staff#3 did not have health screening in the file. Deficiency will be issued. LPAs observed Staff#2(S2) and Staff#3(S#3) do not have the required 40 hours training maintained in their facility file. Deficiency will be issued. LPAs observed Staff#2 and Staff#3 do not have the required 10 hour of initial training, 6 hours of hand on shadowing, and 4 hours of other training or instructions on assisting residence with self- administration of medications. Deficiency will be issued. LPAs observed that staff#2 and Staff#3 do not have the required Dementia training maintained in their file. Deficiency will be issued. Medications/MARs records were audited and appeared to be dispensed and logged appropriately. Based on the observations made during today’s visit, deficiencies were issued and cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) LIC 809C, LIC809D, LIC 421BG(6/17) and Appeal Rights were discussed and provided to Administrator Ariel Angeles