Routine inspection·November 20, 2024

On 11/20/2024 at 09:08 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. Licensee/Administrator Maria Araceli Undan was contacted and informed of the visit. Licensee/Administrator Undan arrived at the facility during the visit. At the time of the visit there were two (2) staff present, and six (6) residents present. The facility is a four (4) bedroom, two (2) bathroom home with a kitchen/dining area, living room/activity room and laundry room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents of which one (1) may be bedridden. The facility’s approved for two (2) hospice waiver. The current census is six (6) residents. LPA Brown was accompanied by Staff #2 (S2) 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). There are no obstructions to indoor passageways. However, LPA Brown observed outdoor passageways not free of obstruction. Deficiency will be issued. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with mattresses, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Brown observed sufficient lighting throughout the facility. However, LPA Brown observed missing one (1) night stand on Room #3 and missing chairs on all resident rooms. Technical Violation will be issued. LPA Brown measured and observed the water temperature in the bathroom to be at 98.9 degrees Fahrenheit. Deficiency will be issued. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguisher was also observed at the facility. Posters such as personal rights, the CCLD complaint poster, ombudsman poster, and the disaster plan were posted in a common area. During the tour of the facility, LPA Brown observed one (1) window screen in disrepair. Technical Violation will be issued. ***Continuation in LIC809C *** In addition, LPA Brown observed Resident #4 (R4) with half bed rail and per staff interview and records review, R4 does not have written order from R4 physician indicating the need for half bed rail for mobility. Deficiency will be issued. Also, LPA Brown observed no night lights maintained in hallways and passages to non-private bathrooms. Deficiency will be issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Cabinet with the resident’s medications locked. LPA Brown observed a complete first aid kit and first aid book at the facility. However, LPA Brown observed the facility does not have the required emergency supplies, food and water. Deficiency will be issued. Food Service : More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision : The facility has an Administrator present at the facility with appropriate and enough hours to appropriately manage the facility. However, based on staff interview and records review, LPA Brown observed no night staff scheduled to work the night shift, awake and on duty, not sleeping at the same time as the residents as required for facility with dementia residents. Deficiency will be issued. Record Review : LPA Brown observed the facility has an updated Liability Insurance. However, LPA Brown observed no Infection Control Plan developed by the Licensee at the facility. Deficiency will be issued. LPA Brown reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals, centrally stored medication list and needs and services plans. LPA Brown observed no pre-admission appraisal completed for Resident #1 (R1) and Resident #3 (R3) and Resident #2 (R2) pre-admission appraisal does not have the required R2's responsible person signature. Deficiency will be issued. Also, LPA Brown observed no completed Preplacement Needs and Services Plan for Resident #2 (R2). Deficiency will be issued. LPA Brown reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA Brown observed that files reviewed were complete. Per records review, LPA Brown observed that the facility were issued the same deficiency for CCR 87303 Maintenance & Operation (e)(2) and HSC1569.695 Other Provisions (e)(2) on 12/28/2023 therefore ***Continuation. in LIC809C*** civil penalty of $250.00 per violation will be issued today, 11/20/2024 for repeating the same violation within 12-month period and will continue to be assessed of $100.00 per day until corrected. Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102TV, LIC421FC and Appeal Rights were discussed and provided to Licensee/Administrator Maria Araceli Undan.