Follow-up·April 8, 2024

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA rang the door bell and was met by Resident 1 (R1). LPA introduced self and asked if any staff were present. R1 took LPA to staff. Staff was assisting another resident and mopping the floor. LPA introduced herself, and explained the purpose of the visit. LPA asked if Staff 1 (S1) was the only staff on shift. S1 was currently the only staff as Administrator Stephanie had a personal appointment. LPA was approached by Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), and Resident (4) upon arrival. LPA spoke to the residents and explained the purpose of the visit. LPA Valerio was met by Administrator Stephanie roughly five to ten minutes later. According to the Administrator, Administrator Stephanie is usually at the facility. LPA requested facility files. According to the staff schedule submitted by the facility Administrator, Administrator Stephanie is scheduled from 7:00 AM - 7:00 PM along with S1, which is on schedule from 7:00 AM - 3:00 PM. Based on observations and records review, the facility did not ensure there was a sufficient number of staff to meet the needs of the residents and did not follow their staff schedule. When LPA arrived there was 1 staff member to care for 13 residents. LPA took a tour of the facility to ensure compliance of Title 22 regulations. LPA observed the facility food supply. LPA took pictures for reference. In the freezer, there was 2 loaves of bread, 3 small bags of frozen meat, and 9 small-medium freezer bags of unknown food items. The bags were labeled with a date but not what type of food in the bag. In the refrigerator, there were sauces and spices on the right door shelves, 1 large mayo container, 1 gallon of milk, 3 containers of left over food items, 2 large packages of meat, 2 bags of carrots, 1 bundle of celery, 3 bell peppers, and 7 tomatoes. In the shed in the back, there were frozen loaves of bread, 4 packs of frozen chicken, 1 large brisket, 1 family size beef. An emergency box of food were observed in the shed. For Lunch, the facility stated they were making tuna sandwiches made from the canned tuna and ravioli soup made from the canned ravioli. Based on LPA's observation, the facility did not ensure to have 2 days of perishable food items, such a fruit and vegetables. Continues on LIC 809 - C... Continued from LIC 809 LPA requested a copy of their LIC 9020 Register of Facility Clients/Residents. LPA requested 3 resident files from the list. LPA reviewed Resident 1 (R1), Resident 5 (R5), and Resident 6 (R6) files. 2 out of 3 files were observed to be incomplete. R1's file was observed to be complete with up to date information. R5's file was observed to be incomplete with a missing signature on the consent for medical treatment form. A Administrator Stephanie stated that R6's file is incomplete because the resident recently moved in. There was no admission agreement in the initial packet that Administrator Stephanie provided. LPA was provided the admission agreement, however, there were portions of the agreement that were not entirely filled out. According to R6's facility file. LPA did not observe a pre-placement appraisal or current appraisal on file. The file had an incomplete face sheet, incomplete admission agreement, Discharge Documents from previous placement, LIC 602 Physician's Report, and Medication Orders. R6 requires Oxygen daily. LPA observed R6's designated room. LPA did not observed oxygen in use signs at the door. TA was provided for the signs. According to the Licensee Justice, residents often rip the signs off from the door. LPA observed the oxygen tank and machine. According to the LIC 602, R6 is able to administer own oxygen. LPA reviewed admission agreements with rental rates. Administrator Stephanie and Licensee Justice stated there are no residents that have received an increase in rental rate. There are two residents, R1 and R5, that are in discussion based on individual circumstances. Administrator and Licensee confirmed understanding of rental increases and stated they provide notices and request signatures prior to the increase. LPA provided Technical Assistance and advised to review Health and Safety Code 1569.655, which states "...the licensee shall provide no less than 60 days' prior written notice to the residents or residents' representative setting forth the amount increase..." Per California Code of Regulations (CCR), Title 22, deficiencies are being cited on the attached LIC 809 - D page. Appeal rights were provided. An exit interview was held with Administrator Stephanie, and a copy of the report was provided.