Routine inspection·October 29, 2024

On 10/29/2024 at 12:50 PM, 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. Assistant Administrator Mary Gonzalez was informed of the visit and met with LPA Brown. At the time of the visit there were 90 residents present. The facility is a seventy-five bedroom and eighty (80) bathrooms with a kitchen/dining area, living room, beauty shop, laundry room. The facility is a Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of one hundred twenty-five (125) non-ambulatory residents and with an approved hospice waiver for ten (10) and the current census is 90 residents. LPA Brown was accompanied by Assistant Administrator Mary Gonzalez 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 75 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean with a water temperature of 107 degrees Fahrenheit and appliances were operating appropriately. LPA Brown observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide detectors were observed. Fire extinguishers were also observed at the facility. Posters such as personal rights, ombudsman poster, labor laws, and the disaster plan were posted in a common area. However, LPA Brown did not observe the CCLD complaint poster. Technical Violation will be issued. During the visit, Assistant Administrator Gonzalez posted the required CCLD poster. LPA Brown tested the call button/pull cord on five (5) residents room and observed the call button/pull cord in good working condition. 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. ***Continuation in LIC809C *** There is a Medicine Room with the resident’s medications locked. LPA Brown observed complete first aid kit with first aid book maintained at the facility. During the tour of the facility, LPA Brown observed Resident #5 (R5) and Resident #6 (R6) with half bed rail but no written order from their physician indicating the need for half bed rail for mobility. 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. However, LPA Brown observed two (2) kitchen staff - Staff #6 (S6) and Staff #7 (S7) with expired food handler certification. Deficiency will be issued. Care & Supervision : The facility has a certified Administrator present during the visit with the required hours to effectively manage the facility. The facility has a sufficient number of staff to provide care and supervision to the residents in care. Record Review : LPA Brown reviewed five (5) resident files for admission agreements, physician reports, pre-placement appraisals, Centrally Stored Medication List, and Preplacements Needs and Services plans/Care Plan. LPA Brown observed that Resident #3 (R3) does not have a completed Pre-Admission Appraisal. Deficiency will be issued. Also, LPA Brown observed that Resident #1 (R1), Resident #2 (R2) and Resident #5 (R5) do not have the required Preplacement Needs and Services Plan/Care Plan. Deficiency will be issued. Moreover, LPA Brown observed Resident #2 (R2) Physician Report was incomplete because it does not have the required physician signature date. Deficiency will be issued. Furthermore, LPA Brown observed Resident #5 (R5) Admission Agreement was not signed by the Licensee/Administrator/Designee. Deficiency will be issued. LPA Brown reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed that files reviewed were complete. During medication audit, LPA Brown observed that staffs at the facility did not assist Resident #1 (R1) and Resident #4 (R4) with their two (2) medications. Deficiency will be issued. Per records review, the facility were cited for the same regulations within 12-month period for California Code of Regulation (CCR) 87465(a)(4) and civil penalty will be issued today, 10/28/2024 with the amount of $1,000.00 for third offense within 12-month period. ***Continuation in LIC809C*** 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, LIC9102, LIC421IM and Appeal Rights were discussed and provided to Assistant Administrator Mary Gonzalez.