Routine inspection·May 5, 2025

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with licensee Beatrice Clark and explained the purpose of the visit. Upon entry, LPA Moleski observed two caregivers working in the facility (S1-S2). LPA Moleski reviewed Guardian records and observed that neither S1 nor S2 were associated to this facility. Clark said S1 had been working at this facility for just under one month. S2 said they had been working at the facility for one month. LPA Moleski asked to review this facility's centrally stored medication records. Clark said she did not have any current centrally stored medication records. LPA Moleski reviewed five resident files (R1-R5) and two staff files (S1-S2). Resident files were missing several required forms. R1 had a blank PRN authorization on file, and had no needs and services plan. R2's appraisal was dated 8/1/23, which is more than one year old. R2 also had a blank PRN authorization form on file. R3 had a needs and services plan on file, but it was not complete and was missing significant pertinent information regarding R3's needs. R4's admission agreement was unsigned, and they did not have an appraisal, personal rights form, consent form, PRN authorization form, or needs and services plan on file. R5 did not have a needs and services plan or PRN authorization form on file. R6 did not have a file present at the facility. Clark emailed LPA Moleski a medical discharge form to LPA Moleski for R6, but could not produce further documentation regarding R6, such as a medical assessment. LPA Moleski asked for S1 and S2's file. Clark said that S2 did not have a file at this facility. S1's file was missing an LIC 501. [continued on 809-C] LPA Moleski toured the facility with Clark 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 77 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 135 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies and carbon monoxide/smoke detectors. While touring, LPA Moleski observed medications in the refrigerator which were not kept in locked storage. LPA Moleski also observed cleaning solutions, including some containing bleach, which were left unlocked in a cabinet under the kitchen sink and under a sink in a resident bathroom. LPA Moleski observed fire extinguishers which had not been serviced within the last year, as required. The fire extinguishers were last serviced on April 15, 2024. This facility is hereby cited per 22 CCR Sections 87202(a), 87303(e)(2), 87309(a), 87355(e)(3), 87465(h)(2), 87412(a), 87506(b), 87465(h)(6). Due to a violation of criminal record clearance requirements, a civil penalty of $100 per day worked by both S1 and S2, with a maximum of five days each, is hereby assessed. An immediate civil penalty in the amount of $500 is also assessed due to a violation of fire clearance requirements. Civil penalties assessed during this visit total $1500. An exit interview was held with Clark. Appeal rights and a copy of this report were left with Clark.