Post-licensing visit·May 19, 2023

Licensing Program Analyst (LPAs) Pang Lee and Avelina Martinez arrived at the facility to conduct an unannounced post-licensing inspection on 05/19/2023 at 8:30 AM. LPA Lee met with care staff Kaydia Sharp and explained the purpose of the visit. Care staff Kaydia assisted with today’s visit. LPAs inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility has one public telephone in the common area. The facility has the required posters posted in the facility. This facility is a single story building licensed to serve four-teen (14) non-ambulatory residents. LPAs observed the facility to be free of odor and clean. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPAs observed exposed wires near and on the fire place area. LPAs observed the emergency exit gate to be not in good repair. In addition, the emergency exit gate was locked. LPAs observed a big piece of glass against the emergency exit gate. LPAs observed two dead birds on the ground, which was located next to the residents' patio area. LPAs also observed screws on the outside fire pit, which is located in a designated resident area. LPAs also observed the fire pit not be in good, and some of the fire pit bricks were broken. LPAs observed a gutter cap was not properly installed, which is a tripping hazards to residents in care Furthermore, during the pre-licenseeing process, the licensee agreed to installed an exterior vinyl hallway enclosure that would protect residents from the outside elements. Also, the Department received an email on January 2, 2023 from the Licensee confirming that a vinyl enclosure would be installed to fully cover the residents bathroom passage way to ensure residents are able to go to and from bedroom to bathroom number three. However, during today's visit LPAs observed the vinyl enclosure was taken down, and parts of the vinyl enclosure were left on the ground causing a tripping hazard (Wood Boards). As a result, the Licensee is not following the plan of operation and the agreed upon terms. Continued LIC 809-C LPAs observed sufficient seven day non-perishable and two day perishable food supplies. The resident bathroom water temperature measured at 118.8 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. Fire extinguisher was last serviced on 09/21/2022. Facility thermostat observed at 72 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients. LPA Lee reviewed 3 out of 6 medication administration record (MAR) and it was complete. First aid kit was checked and is complete. LPA Lee requested client and staff files for review. LPAs reviewed 3 out of 6 client files and 3 out of 3 staff files and they were not complete. LPAs 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; however it was learned that two out of three facility staff were not associated to the facility. Moreover, the facility staff 1, 2, and 3 files did not have training documentation. Staff 3 (S3) did not have LIC 501 Personnel Record or Application. Moreover, the facility did not maintain resident records. Resident 1 (R1) and resident 3 (R3) admission agreement Addendum contain inaccurate information. The addendum is for facility Abounding Love. An immediate $500.00 civil penalty shall be assessed on May 19, 2023; based on observation: "Facility is not adhering to their approved fire clearance." Violation of California Code of Regulations Section 87203 (a) was assessed on 05/19/2023 b ecause the facility did not adhere to fire clearance and fire safety regulation. An immediate $500.00 civil penalty shall be assessed on May 19, 2023; based on observation and review "Facility is not adhering to personnel requirements/background association of employees." Violation of California Code of Regulations Section 87411 (g) was assessed on 05/19/2023 because the licensee did ensure that staff 2 and 3 were associated to the facility prior to working. An exit interview was conducted, and a copy of the LIC 9099 report, LIC 9099-D, and appeal rights were given to the facility. As a result of this post pre-licensing visit, the facility is not in compliance with Title 22 Regulations, 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.