Routine inspection·April 18, 2024

On 04/18/2024 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee and Support staff (SS) Perla Mancillas arrived at the facility to conduct an unannounced annual inspection. LPA and SS met with direct care staff, Veniana Banuve and explained the purpose of the visit. Direct care staff called administrator, Una Wagalala. LPA and SS was informed that administrator is not able to join the visit and that direct care staff Veniana will assist with today’s visit. Administrator certificate # is 6056441740 and will expire on 07/08/2024. The current census is 13 with 3 facility staff. This facility is a single story building licensed to serve fifth teen (15) non-ambulatory residents and approved for 1 hospice residents. LPA and SS inspected the physical plant including but not limited to the common area, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. It was observed the facility was free of odor, clean and in good repair. LPA and SS observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA and SS observed residents’ room 101 was occupied by two facility staff which does not reflect the facility sketch and fire clearance. LPA and SS observed a folded roll out bed in residents’ room 102. It was learned that a staff sleeps on the roll out bed either in the activity room or the living room. It was also observed that the resident bathroom inside bedroom 102 is locked during the day and open for resident’s use at night due to the toilet leaking. LPA Lee did not observed any leak in the bathroom during today's visit. LPA and SS toured the kitchen and observed the pantry locked and not accessible to residents at this time. The facility had sufficient seven day non-perishable food supplies. It was observed that two day perishable food supplies were not sufficient for 13 residents in care. Hot water temperature was measured at 130.1 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 04/03/2024. LPA and SS observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. The facility has an infection control plan and an emergency disaster plan. Facility thermostat observed at 72 degrees Fahrenheit. LPA and SS observed toxins located in the hallway closet and kept locked and inaccessible to residents. LPA and SS observed sharp knives kept locked and inaccessible to residents. LPA and SS checked medication storage and found medication to be locked away and inaccessible to residents. LPA and SS reviewed and compared 4 medication administration record (MAR) along with residents’ medications. Records reviewed indicated that 1 out of 4 MAR log was inaccurate. Three out of 9 medication instruction did not have the current instruction information. The first aid kit was checked, and it was missing the thermometer. LPA Lee requested resident and staff files for review. LPA Lee reviewed 6 out of 13 resident files and 3 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents will be email to LPA Lee ( pang.lee@dss.ca.gov ) by 04/26/2024 by 5:00 PM by end of day: (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610 Emergency Disaster Plan (5) Proof of Current Liability Insurance 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 staff Veniana Banuve.