Routine inspection·November 15, 2023

On 11/15/2023 at 08:45 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Administrator Richie Garcia, and was granted entry to the facility. At the time of the visit there were three (3) staff present, and three (3) residents present. The facility is a eleven (11) bedroom, eight (8) bathroom home with a kitchen/dining area, living room. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of fourteen (14) non-ambulatory residents and the current census is twelve (12) residents. LPA Brown was accompanied by Administrator Garcia 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 (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA 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. Resident #1 (R1) did not have lamp in their bedroom. The shower in Room #2, Room #3 and Room #8 did not have a non-slip mat on the shower floor. During the tour of the facility, LPA Brown observed that Resident #12 has a half bedrail and no written order from R12's physician indicating the need for the postural support maintained in R12's facility record . Also, LPA Brown observed the side gate secured and locked with padlock. This poses an immediate and potential health, safety risk to residents in care. Deficiencies will be issued for the lamp and the non-slip mat and for locking/securing the side gate with padlock. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathroom to be at 110 degrees F. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. ***Continuation in LIC809C *** 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 cabinet with the majority of the resident’s medications locked in the medication room. However, LPA Brown found residents medications pre-poured in a small container for the day, up to bedtime medication for each resident at the facility. The facility will be issued a deficiency for medication issue. Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. Care & Supervision: The facility has an administrator present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans. The files were complete with updated physician’s reports, admissions agreements, and preadmissions appraisals. LPA reviewed six (6) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA found that six (6) of the six (6) staff have CPR training, staff are properly trained in medication, dementia care, and basic training required for an RCFE. Medications/Medication Administration Record (MAR) were audited and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, four (4) 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 Administrator Richie Garcia.