Routine inspection·August 26, 2024

On 08/26/2024 at 09:24 AM, Licensing Program Analysts (LPAs) Renese Howell-Small, Raquel Hernandez and Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs Howell-Small, Hernandez and Brown met with a staff and was granted entry to the facility. Executive Director (ED) Brittney Martinez was informed of the visit and met with LPAs Howell-Small, Hernandez and Brown. At the time of the visit there were twelve(12) staff present, and thirty-six (36) residents present. The facility is a fourty-five (45) bedroom, fourty-five bathrooms (45) bathrooms with a kitchen/dining area, living room/activity room. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of sixty (60) non-ambulatory residents and with approved hospice waiver for twelve (12) and the current census is thirty-six (36) residents. LPAs Howell-Small, Hernandez and Brown were accompanied by ED Martinez 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 and outdoor passageways. The facility is maintained at a comfortable temperature of 71 degrees Fahrenheit. LPAs Howell-Small, Hernandez and Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs Howell-Small, Hernandez and Brown observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating combined smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCLD complaint poster, ombudsman poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** LPA's Howell-Small, Hernandez and Brown tested the pull cord on 08/26/24 at 11:23AM in Resident's room#5 and waited for ten minutes. LPA's observed that the pull cord is in disrepair. 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 Room with the resident’s medications locked. LPAs Howell-Small, Hernandez and Brown observed complete first aid kit but no first aid book maintained at the facility. A deficiency will be issued. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than three (3) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. All kitchen staff have their updated ServSafe Certification and Food Handlers’ card. Care & Supervision: The facility has an Executive Director present in the facility with appropriate and enough hours to effectively manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA's Howell-Small, Hernandez and Brown reviewed five (5) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA's Howell-Small, Hernandez and Brown observed resident files reviewed were complete. LPA's Howell-Small, Hernandez and Brown reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA's Howell-Small, Hernandez, Brown observed that files reviewed were complete. However, during medications audit, LPA's Howell-Small, Hernandez and Brown observed Resident #8 (R8) three (3) medications were not given according to R8 physician's directions, as evidenced of the 3 medications were observed to be missing in the medication room. Also, two (2) of Resident#9 (R9) medications were observed to be missing in the medication room. A deficiency will be issued. 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 forms, and Appeal Rights were discussed and provided to Executive Director Brittney Martinez.