Routine inspection·December 13, 2023

On 12/13/2023 at 09:00 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 Staff #2 (S2), was granted entry to the facility. At the time of the visit there were three (3) staff present, and six (6) residents present. Administrator Alicia Cunningham was contacted and arrived during the visit. The facility is a seven (7) bedroom, three (3) bathroom home with a kitchen/dining area, living room and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of twelve (12) residents of which (6) can be non-ambulatory residents and six (6) ambulatory residents. The facility has two (2) Hospice Waiver and side chain links may be locked in evenings. The current census is ten (10) 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 (CCL). LPA Brown observed no obstructions to outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown 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 Brown observed non-skid mat or strips in the resident bathrooms. Also, LPA Brown observed Resident #5 (R5) with full bed rails and Administrator Alicia Cunningham reported to LPA Brown that R5 is not on Hospice Care and no written order from the 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 R5's full bed rails. Deficiency will be issued. ***Continuation in LIC809C *** To add to that, LPA Brown observed Resident #1 (R1), Resident #2 (R2), and Resident #9 (R9) have half bed rails but no written order from R1, R2 and R9 physician indicating the need for postural support explaining R1, R2 and R9 needed assistance for mobility maintained in R1, R2 and R9 record. Deficiencies will be issued. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 116 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Personal rights and the Ombudsman poster were observed but no CCL complaint poster and the no disaster plan were posted in a common area. Deficiencies will be issued. LPA Brown observed no available Monthly Activity Calendar at the facility. Deficiencies will be issued. Moreover, during the tour of the facility, LPA Brown observed that there was a designated storage space for resident/staff files. There is a cabinet with the majority of the resident’s medications locked. However, LPA Brown found medications pre-poured in a partitioned container for the day, up to bedtime medication for each resident at the facility. LPA Brown explained that no medications shall be pre-poured and transferred between containers. The facility will be issued deficiencies for pre-pouring residents medications for the day up to bedtime as this pose immediate health, safety and personal rights risks to residents in care. Food Service: Seven (7) days non-perishable food and three (3) days perishable food supply were observed at the facility. Care & Supervision: The facility has an administrator present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA reviewed ten (10) resident files for admission agreements, updated physician reports, and needs and services plans. The files were complete for eight (8) residents with updated physician’s reports, admissions agreements, and Pre-placement appraisals and Appraisal/Needs and Services Plan. However, LPA Brown observed missing Appraisal/Needs and Services Plan for Resident #7 (R7) and Resident #8 (R8). Deficiency will be issued. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found that all staffs have CPR training, staff are properly trained in medication, dementia care, and basic training required for an RCFE. However, LPA Brown observed Staff #3 (S3) criminal background clearance was not transferred to the facility. S3 reported to LPA Brown that S3 started working at the facility 11/28/2023. ***Continuation in LIC809C *** LPA Brown informed Administrator Cunningham that deficiency will be issued and civil penalty of $500.00 will be issued during the visit as this pose potential health, safety and personal rights risk to residents in care. Furthermore, LPA Brown observed no Fire Drill and Earthquake Drill Log or record at the facility and no Infection Control Plan at the facility. Deficiencies will be issued. Also, LPA Brown observed no current edition of a first aid manual approved by American Red Cross, the American Medical Association or a state or federal health agency at the facility. Technical Violation will be issued. Medications/Medication Administration Records (MARs) records were audited and LPA Brown observed that medications were dispensed for R1 and R9 without record, no December 2023 MAR available for R1 and R9. LPA Brown requested for any record that the facility have for dispensing R1 and R9 December 2023 medications per R1 and R9 physician's order but S3 and Administrator Cunningham reported to LPA Brown that no available record of dispensed medication per R1 and R9 at the facility. Deficiency will be issued. Based on the observations made during today’s visit, eleven (11) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC809D, LIC421BG, LIC9102 forms, and Appeal Rights were discussed and provided to Administrator Alicia Cunningham.