Routine inspection·February 20, 2025

On 02/20/25, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with administrator Cleopatra Gardiner and explained the purpose of the visit. The current census is 13 with 3 facility staff. This facility is a single story building licensed to serve fourteen (14) non-ambulatory residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. At 1:16 PM, LPA observed a knife made accessible to residents in care. LPA observed the administrator and another staff member preparing lunch for the residents. After lunch was served, the knife was placed in the kitchen sink, and staff walked away. LPA addressed this issue with the administrator, who then locked the knife in a kitchen cabinet. Additionally, LPA observed toxic substances were stored under the kitchen sink, and it was unlock making it accessible to residents. LPA advised the administrator to secure the cabinet. LPA and the administrator also tested two residents’ call pendants, which appeared to function properly but did not emit an auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. Hot water temperature was measured at 111.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Continued LIC 809- Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 02/13/25. LPA observed the facility has a has a public telephone in the kitchen. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 6 out of 13 residents’ medications and medication administration record (MAR) and it was complete. The first aid kit was checked and contained the required components. LPA requested residents and staff files for review. LPA reviewed 7 out of 13 resident files and it was incomplete. Based on records review LPA observed the following in residents’ file: · R3 did not have LIC 601 · R4 LIC 601 was incomplete. · R6 LIC 601 is incomplete, LIC 627C is blank and needs resident and administrator’s signature. · R7 LIC 625 is missing administrator’s signature. LPA Lee also reviewed 3 staff files, and they were also incomplete. Based on records review LPA observed the following in staff files: · Staff 1(S1) LIC 501 is missing staff’s previous employment and education. LPA also did not see first aid/CPR in the staff file. · S2 LIC 501 is missing employment and education. · S3 does not have 20 hours of continual education for 2024. During today’s visit, the administrator addressed and corrected the incomplete documents for both residents and staff. Administrator was able to locate S1’s first aid/CPR certificate. LPA 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 and associated to the facility. The following documents will be email to LPA during by 02/26/25 end of day 5:00 PM. (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610D Emergency Disaster Plan (5) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, 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.