Health check·February 16, 2024

Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a health and safety case management visit. The facility is on quarterly visits due to non-compliance concerns discussed during a zoom meeting on 11/14/2023. LPA Lee met with licensee, Edna Clegg and explained the purpose of the visit. The census is 6 with 2 facility staff. At 8:31 AM, LPA Lee entered the facility and observed three residents sitting in the common area watching a movie. The residents appeared to be clean and comfortable. LPA Lee and licensee Edna Clegg toured the physical plant to ensure compliance with Title 22 regulations. LPA Lee observed resident bedrooms, bathrooms, common areas, dining area, laundry room, kitchen, and exterior plants of the facility. LPA Lee observed resident bedrooms to have the necessary furniture and furnishings. The temperature inside the home was measured at 72*F. LPA Lee observed the fire extinguisher located in the kitchen next to the pantry. The fire extinguisher was last serviced on 12/01/2023. LPA Lee observed the carbon monoxide and fire alarm was in good repair. LPA Lee observed no emergency exits were obstructed. The first aid kit was checked and contained all the required components. At 8:43 AM, LPA Lee also observed multiple chemicals made accessible to residents in care . At 8:45 AM , LPA Lee observed a mini refrigerator out in the dining area unlocked. LPA Lee observed 4 water bottles, 1 Sunsweet prune juice and a 26 Fl oz Phillips milk of magnesia inside the mini refrigerator. It was learned that magnesia is for resident 1 (R1) and there is no PRN order and doctor’s note for (R1). Based on interview, licensee Edna Clegg admitted to buying (R1) the Sunsweet prune juice for (R1) constipation without a doctor’s order or note. LPA Lee advised licensee that any resident PRN medication needs a doctor’s order or a doctor’s note. LPA Lee also advised licensee that she can not give (R1) prune juice without a doctor’s order or note. Continued LIC 809-C At 8:48 AM , LPA Lee observed a knife on top of the kitchen counter and two scissors on the dish rack made accessible to residents in care. LPA Lee asked the licensee where she kept sharp objects and the license stated that she keeps them in a drawer below the dish rack. LPA Lee observed the drawer unlocked and inside the drawer LPA Lee observed four knives. Licensee continues to show LPA Lee where the additional knives are kept as well. Additional knives were kept on a kitchen shelf made accessible to residents . At 8:52 AM , LPA Lee observed (R2) Latanoprost medication and licensee eye drops in the refrigerator made accessible to residents and stored with condiments. Licensee admitted that (R2) is no longer taking (R2) Latanoprost medication. Based on observation (R2) Latanoprost medication was supposed to be discarded after 09/30/2021. During today’s visit, LPA Lee observed licensee removed (R2) and licensee’s eye drop from the refrigerator. LPA Lee advised the licensee that all sharp objects and chemicals need to be locked at all times. LPA Lee also advised licensee that all resident’s medication needs to be made inaccessible to resident at all times. LPA Lee also advised licensee that medications cannot be stored with food. Based on observations today, at 8:55 AM , LPA Lee observed resident bathroom #1 toilet seat was not in good repair. The top of the seat is broken. The toilet was also observed to be unclean. During the inspection Licensee cleaned the toilet and apologized for it being unclean. LPA Lee also observed licensee fixed broken toilet. The resident bathroom observed to have handrails and non-slip mat. At 8:57 AM , LPA Lee observed resident bedroom #4 sliding door is hard to open and the sliding screen is not in good repair due to rips and holes. Based on records review at 9:10 AM, LPA Lee observed waterlog only from 09/01/2023 to 09/11/2023. At 9:30 AM, LPA Lee measured the water temperature and it a measured at 115.2 degrees Fahrenheit which is within the required regulations of 105 to 120 degrees Fahrenheit. Based on records review and interviews with licensee Edna and caregiver Maxwell Llorente admitted to not having a maintenance and ground checklist completed. Maxwell stated that he will create a maintenance and ground checklist and provide it to LPA Lee. At. 10:29 AM, LPA Lee observed a small tray of snacks out in the dinning island counter. Inside the tray were 8 small packs of 0.2 oz of Frootloops cereal and 1 pack of 6 oz Whisp Cheese Crips bag. At 10:37 AM, LPA Lee observed 10 of (R1) medication Clobetasol Propionate lotion in an unlocked cabinet in the laundry made accessible to residents. During today’s visit, LPA Lee observed licensee removed (R2) and licensee’s eye drop from the refrigerator. Continued LIC 809-C LPA requested to review resident files and staff files. LPA Lee reviewed 6 out of 6 resident files and 4 out of 6 staff files, and they were not complete. LPA Lee observed 6 out of 6 resident’s LIC 625 Appraisal Needs and Services was completed; however, it does not have licensee and residents’ signature. LPA Lee also observed 6 out of 6 residents missing LIC 601 in the file. LPA Lee observed 4 out of 6 facility staff files missing 20 hours of continued education for the year 2023. LPA Lee reviewed and compared 6 out of 6 residents medication records. Licensee stated that she does not use the MAR to administer residents’ medication. It was learned that licensee uses the Centrally Store Medication Destruction Record (CSMDR); however, based on records review and observations the licensee did not keep adequate records of the (CSMDR) for 6 out of 6 residents. LPA Lee observed (R3) (CSMDR) last start dated was 03/11/2022. LPA Lee observed (R2) (CSMDR) last start dated was on 02/07/2019. In addition, (R2) (CSMDR) shows (R2) has medication Benztropine 0.05 mg; however, the medication was not in resident medication box. Licensee admitted that (R2) is no longer take Benztropine. LPA Lee also observed 5 out of 6 residents (CSMDR) does not have a start date of when all of resident’s medication was administer to residents. As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.