Routine inspection·April 13, 2023

Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 04/13/2023 at 8:30 AM. LPA met with Kohata Qalo and stated the purpose of today’s visit. LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. Administrator holds current certificate. The facility is licensed for six non-ambulatory residents. There are currently six residents who reside at this facility. The facility has an approved hospice waiver for one resident. LPA Martinez toured the facility with Kohata Qalo on 04/13/2023 at 11:00 AM. LPA Martinez reviewed six out of six resident files, and the files were up to date. LPA Martinez reviewed four out of four staff files, and the files were up to date. LPA Martinez reviewed 2 out of 6 residents' Medication Administration Records (MAR). Resident 3 (R3) was missing a doctor's order for PRN Medication Acetaminophen 300 MG. In addition, Gabapentin 300 MG medication order label was altered with a black marker. Staff 1 also reported they altered the Gabapentin administration order label. In addition, March and April 2023 MAR states Gabapentin take 25 MG: 1 capsule by mouth 3 times per day. January 2023 MAR states Gabapentin 300 MG take 2 capsules 3 times per day. As a result, the facility will need to obtain an updated doctor's order for Gabapentin and correct April MAR. Resident 5 (R5) MAR was up to date. Continued... During the tour, it was observed R3 was residing in a non-designated resident room. Per License posted at Facility and per Fire Clearance form STD 850 Bedrooms four and five are not permitted for client use. The facility sketch will need to be updated, and bedroom change arrangements need to be implemented for R3. An immediate civil penalty was assessed on April 13, 2023 in the amount of $500.00 for fire clearance violation Title 22 regulation Fire Safety 87203 . The facility smoke detectors, carbon detectors, and fire extinguishers are in good repair. Last fire drill was conducted in February 2023. The facility has a first aid kit. The facility common areas and resident bedrooms were furnished and in good repair. The facility bathrooms were sanitary, and water temperature measured at 106 degrees. The facility temperature measured at 75 degrees. The facility had an adequate food supply, and the kitchen was sanitary. The exterior of the home was maintained, and the emergency exit gate was clear of debris. As a result of this annual inspection, deficiencies can be found on the 809-D page. An exit interview was conducted, and copy of this report was provided to the facility. Also, a copy of the appeals rights document was provided to the facility.