Routine inspection·December 6, 2023

On 12/6/2023 at approximately 1PM, Licensing Program Analyst (LPA) Cassie Yang arrived at the facility unannounced to conduct a Required 1-year annual inspection utilizing the CARE inspection tool. At time of arrival, LPA observed the presence of Metro Fire arrival. LPA met with Caregiver and Administrator at the door, and explained the purpose of the visit. Today's census is four with one resident on hospice services. Time of visit, LPA observed R1 to be transported to hospital for evaluation. LPA reminded Administrator to submit LIC 624 regarding R1's hospital transportation. LPA and Administrator conducted a tour of the facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, (4) resident bedrooms, (2) bathroom, kitchen, laundry room and staff office/room. In the areas toured the following issued were observed: LPA observed the CCLD compliance poster (PUB 475) to be missing. LPA observed fire door to be opened using a door stopper. LPA observed fire extinguisher to b e in need of service as last inspection was 10/17/2022. LPA observed sharps to be stored in an unsecured drawer. LPA observed R2 and R3 to be non-ambulatory based on file review and observed R2 and R3 to be residing in an ambulatory only room. LPA conducted a resident file review. LPA observed 4 of 4 files are incomplete for various required forms. Administrator stated he is in the process of completing all documents based on LIC 311F checklist. LPA conducted a personnel file review. LPA observed 1 of 2 files are incomplete for forms and training. LPA observed S2 to not have a personnel file. LPA observed no proof of CPR and First Aid training present on file. LPA observed S1 to be working at the facility which she "arrived five days ago" without any fingerprint clearance. LPA informed Administrator staff cannot work at the facility until the individual is fingerprinted and cleared. Please continue on LIC 809-C... LIC 809-C... LPA provided LIC 9182 to Administrator for clearance transfer as LPA observed facility to have only S2 associated to the facility. LPA provided LIC 311F to Administrator for file completion. LPA is requesting liability insurance to be provided to LPA Yang via email by Friday December 8, 2023. LPA and Administrator discussed submitting a new LIC 200 and facility sketch to LPA for a new fire inspection for 5 non-ambulatory and 1 ambulatory. As a result of this inspection, the following deficiencies were cited on LIC 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Exit interview conducted with Administrator. Signature confirming documents were received was conducted with Caregiver who entered the facility shortly before exit interview. LPA received physical copy of LIC 9182 for S3. Report and appeal rights provided.