Routine inspection·April 22, 2025

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Sherry Ahuja and explained the purpose of the visit. Upon entry, LPA Moleski observed an individual working in the kitchen (S1). S1 identified themselves to LPA Moleski. S1 initially said they were at the facility visiting someone. LPA Moleski had already spoken with another staff member (S2), who said S1 started training last week. After LPA Moleski relayed this information to S1, S1 admitted that they were here for caregiver training. Ahuja said that S1 started training on either April 16 or 17. LPA Moleski observed in the facility garage a bed and personal effects. S1 said they had been sleeping in the bed, and that some of the effects were theirs. This facility is not cleared for residential use of the garage area. LPA Moleski reviewed Guardian records and observed that S1 does not have a criminal record clearance. S1 had no personnel record on file. Ahuja said she wanted to help out S1 by giving them a place to stay. LPA Moleski reviewed six resident files (R1-R6) and three staff files (S2-S4). S4's file did not contain an LIC 501, LIC 508, or first aid/CPR certification. LPA Moleski observed in a resident's file (R1) medical documentation showing that R1 visited the hospital on 2/10/25 due to a wound on R1's foot. According to Ahuja, a wound on R1's foot had gotten worse, and needed medical attention. R1 was placed on hospice care after this visit, according to Ahuja. LPA Moleski reviewed fax and email records and observed no incident report was received by the Community Care Licensing Division (CCLD) regarding this incident. Additionally, no notification was made when R1 started receiving hospice care. LPA Moleski observed in another resident's file (R2) medical documentation showing that R2 was hospitalized and placed on a 5150 hold on 3/13/25. According to Ahuja, R2 was hearing voices and was experiencing paranoia, so they were taken to the hospital. [continued on 809-C] LPA Moleski reviewed fax and email records and observed that no incident reports were received by CCLD regarding this incident. LPA Moleski observed in another resident's file (R4) medical documentation showing that R4 was sent to the hospital due to a lice infestation. CCLD received no incident report of this, according to fax and email records. While reviewing R4's medication administration records (MARs), LPA Moleski observed a lice treatment medication for R4 which was to be taken once per day, according to the MARs and according to the centrally stored medication records sent by R4's pharmacy. The medication was filled as of 3/11/25, according to the MARs. LPA Moleski observed that R1 received the medication at sporadic intervals, sometimes once every other day, once every two days, or with multiple days in between doses. S2 said that R4 did not receive the medication every day because R4 did not receive a shower every day. This facility has two scheduled shower days per week per resident. LPA Moleski asked for the prescription order for this medication, but Ahuja was not able to immediately produce it. Ahuja obtained an electronic copy and sent it to LPA Moleski. LPA Moleski toured the facility with Ahuja 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 103 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees. 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 closet 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 (R3).This facility is hereby cited per 22 CCR Sections 87202(a), 87355(e), 87465(a)(4), 87211(a)(1), 87303(e)(2), 87412(b), and 87632(d)(2). Due to a violation of fire clearance, an immediate civil penalty of $500 is hereby assessed. Due to a violation of criminal record clearance requirements, a civil penalty in the amount of $100 per day of S1's work and/or residence at this facility, with a maximum of 5 days, is hereby assessed. Civil penalties assessed during this visit total $1000. An exit interview was held with Ahuja. Appeal rights and a copy of this report were left with Ahuja.