Routine inspection·March 22, 2024

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Caroline Armstrong, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (6) and a hospice waiver for (5). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor activity area is fenced and sufficient for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s showers, toilets, and hand washing areas were operating in a safe and sanitary condition. The hot water temperature in residents' bathrooms measured 118 degrees F. Resident’s bedrooms audited had sufficient lighting, beds, bed linen and dressers. Facility has operating carbon monoxide alarms and telephone service. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, Personal Rights, Theft and loss plan, and evacuation exit plan. Food Service: The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps were kept locked and inaccessible to residents in care. LPA observed uncovered perishable food items in kitchen refrigerator. Deficiency cited. Care & Supervision : Facility has 24-hour, 7 days a week direct care staff. Record Review: LPA review of resident files reveals, resident #1 (R1) did not have a preadmission appraisal on file for review. LPA requested record of an infection control plan, a quarterly emergency drill, and staff training and criminal record clearance files; however facility staff did not know where the documentation was kept. Medical Related Services : LPA review of resident medications reveals, medications for prescribed for resident(s) (R1), (R2), (R3), (R4), and (R5) were not all documented and did not have a record of dosages listed on file. LPA observed in R3's medication box, a medication that was missing the name of medication, dosage, and instructions. LPA also observed in R3's medication box, medication stored in a zip-lock bag with no prescription label. Based on observations and record review, deficiencies are being cited per Title 22, of The California Code of Regulations and Health and Safety Codes. An exit interview was conducted where the Licensing reports were reviewed. Copies of the reports were provided with Appeal Rights to the Administrator at the conclusion of the visit.