Post-licensing visit·August 21, 2023

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a postlicensing inspection. LPA Moleski met with facility administrator Salote Lewis and explained the purpose of the visit. LPA Moleski reviewed Lewis' file, a staff member's file (S1) and two resident files (R1-R2). This facility currently has two residents. R1 is age 75. R2 is age 34. Less than 75 percent of this facility's residents are over the age of 60. R1 was admitted on 8/8/23, according to R1's admission agreement. R1's admission agreement was not signed by R1 or a responsible party as of this visit date. R1's LIC 602 is dated 7/1/2022, which is more than a year prior to admission. R1's Identification and Emergency Information form is blank and is unsigned, and therefore did not contain a name, address, or phone number of a physician and dentist to be called in an emergency. Lewis said she had not received completed and signed documents back from R1's conservator. While reviewing medication administration records (MARs), LPA Moleski observed two missed doses for R1. R1 did not receive a nighttime dose of one medication on 8/8/23, and did not receive a midday dose of a different medication on 8/17/23, according to the MARs. LPA Moleski toured the facility with Lewis 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 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 116 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. [continued on 809-C] While inspecting a facility bathroom, LPA Moleski and Lewis observed a bottle of toilet bowl cleaner left in an unlocked cabinet. While inspecting the backyard, LPA Moleski and Lewis observed an unlocked shed containing unsecured cans of paint and bags of drywall joint compound. 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 (S1) and two residents (R1-R2). This facility is being cited per the applicable 22 CCR Sections. An exit interview was held with Lewis. Appeal rights and a copy of this report were left with Lewis.