Routine inspection·October 14, 2024

On 10/14/2024 at 09:15 AM, Licensing Program Analysts (LPA) Melody Brown and Eldin Serrano made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection LPAs Brown and Serrano met with Assitant Resident Care Coordinator Gwendolyne Galvan and was granted entry to the facility. At the time of the visit there were twenty seven (27) staffs present, and one hundred thirty three (133) residents present. The facility is a eighty four (84) bedrooms, eighty four (84) bathroom facility with a kitchen/dining area, living room/activity room, TV room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of eighty six (86) ambulatory, one hundred fifty (150) non ambulatory, fifteen (15) hospice care and 15 maybe bedridden resident and the current census is one hundred thirty three (133) residents. LPAs Brown and Serrano was accompanied by ARCC to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperatures in the bathroom for room #104 to be at 114.4 degrees Fahrenheit, Room# 246 to be at 115.8 degrees Fahrenheit, Room #311 to be at 115.1 degrees Fahrenheit . The facility is equipped with operating smoke detectors and did not observe carbon monoxide alarms. LPAs observed that the facilty do not have the required carbon monoxide detector installed on each floor of the facility. Deficiency will be issued. ***Continuation in LIC809C *** ***Continuation in LIC809C *** Fire extinguishers were observed on every floor at the facility. Posters such as personal rights, the CCLD complaint poster, ombudsman poster, labor laws, and the disaster plan were posted in a common area. LPAs obeserved resident #1 (R1) and resident #2 (R2) with half bedrail but per interview and documents review there is no written order from their physician indicating the need for half bed rail for mobility, Defiiciency will be issued. LPAs observed floor surface in resident bathroom and the floor bathroom for residents and staff were not clean. Deficiency will be issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine Room with the resident’s medications locked. LPAs observed complete first aid kit and first aid book at the facility. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has no Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. Based on interview and LPAs observation facility administrator was not present at the facility for three (3) consecutive weeks and not at the facility during working hours. Deficiency will be issued. Record Review: LPAs reviewed five (5) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPAS observed resident #2 (R2) does not have the required pre-placement appraisal. Deficiency will be issued. LPAs observed Resident #2 (R2) #3 (R3) and #4 (R4), does not have the signed and dated admission agreement. Deficiency will be issued. LPAS observed no completed needs and services for resident #5 (R5) and facility representative did not sign the completed needs and services plan for resident #2 (R2) and resident #4 (R4). deficiency will be issued. LPAs reviewed five (5) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) Test result. LPAs observed staff #4 (S4) does not have the required tuberculosis (TB) test and TB test result. Deficiency will be issued. LPAs observed staff #3 (S3) does not have the required updated ServSafe certification and staff #4 (S4) does not have the required update food handlers card. Deficiency will be issued. Medications/Medication Administration Record (MAR) were audited for 5 residents and no issues observed. However, LPAs observed resident #3 (R3) does not have the required annual medical assessment as required for resident with dementia as R3s medical assessment date is 08/12/2022. Deficiency will be issued. Also, LPAs observed that resident #2 (R2) is in memory care and per documents review R2 does not have a diagnosis of dementia but with a primary diagnosis of a mental disorder unrelated to dementia. Deficiency will be issued. Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC809D forms, and Appeal Rights were discussed and provided to Assistant Resident Care Coordinator Gwendolyne Galvan.