Routine inspection·March 3, 2025

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Mohamed Massaquoi and explained the purpose of the visit. Upon arrival, LPA Moleski observed two staff members present (S1-S2). S1 said they had been working at this facility for one week. Massaquoi said that S1's start date was Wednesday, 2/26/25. LPA Moleski reviewed Guardian records and observed that S1 was associated to this facility as of 3/1/25, but was not cleared prior to that date. S2 said that they had been working at this facility for three years on an on-call basis. LPA Moleski reviewed Guardian records and observed that S2 was not associated to this facility. LPA Moleski reviewed five resident files (R1-R5) and one staff file (S2). S1 did not have a personnel file. Massaquoi said he was still working on completing S1's file. Massaquoi said that S2's personnel file was located at another facility. Massaquoi left and returned with S2's file, which was missing several required elements. R1 moved in as of 3/2/25. R1 did not have a medical assessment [LIC 602] on file prior to admission. R1's pre-placement appraisal was partially completed, and indicated that R1 is non-ambulatory, but did not include an appraisal of R1's health history, mental condition, or any social factors. The partially completed pre-placement appraisal was not signed by R1 and/or R1's responsible parties, but was signed by Massaquoi. R2's pre-placement appraisal was signed by all parties, but was signed on 2/27/25, one day after their admission date of 2/26/25. R4, who was admitted on 2/18/25, did not have any pre-placement appraisal on file. Additionally, R4's LIC 602 did not include any tuberculosis test results or the results of a chest x-ray. LPA Moleski reviewed four residents' LIC 602s (R2-R5). As previously mentioned, R1 did not have an LIC 602 on file. R2-R5 all had LIC 602s which identified them as non-ambulatory. [continued on 809-C] R1's pre-placement appraisal, which was signed by Massaquoi, identified R1 as non-ambulatory. LPA Moleski also observed R1 using a wheelchair during this visit. This facility has a fire clearance which permits admission of no more than four non-ambulatory residents. None of these non-ambulatory residents are permitted to reside within bedroom #3, according to this facility's fire clearance. LPA Moleski toured the facility with Massaquoi and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 76 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 131 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees. While touring the facility, LPA Moleski observed multiple cleaning solutions left in unlocked cabinets in resident bathrooms, including cleaners which contained bleach. LPA Moleski asked Massaquoi for the residents' centrally stored medication records. Massaquoi was not able to produce centrally stored medication records which included start dates or dates that prescription orders were filled for any resident. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski interviewed one staff member (S2) and one resident (R4). This facility is hereby cited per 22 CCR Sections 87202(a), 87355(e)(3), 87457(c)(1)(A), 87458(a), 87458(c)(1), 87412(a) , 87465(a)(6) , 87303(e)(2), 87309(a)(1) . An immediate civil penalty in the amount of $500 is hereby assessed due to a violation of fire clearance. Civil penalties for violations of criminal record clearance are assessed in the amounts of $100 per day worked without criminal record clearance/association per staff member. Civil penalties are assessed for a maximum of five days worked by S2 and three days worked by S1 [2/26/25 - 2/28/25] prior to clearance/association. Combined, all civil penalties assessed during this visit total $1,300. An exit interview was held with Massaquoi. Appeal rights and a copy of this report was left with Massaquoi.