Routine inspection·December 11, 2024

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Maria "Teresa" Datuin, Administrator, and discussed the purpose of the visit. The facility is a three (3) building, Residential Care Facility for the Elderly (RCFE) with a license capacity of (18) and a current census of (9) residents in care and hospice waiver for (4). 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 gated and sufficient for client activities. The facility has sufficient lighting and is maintained at a 71 degrees F. The facility has operating carbon monoxide/smoke alarms, laundry equipment, signal system and telephone service. Resident 3 1/2 bathroom equipment were operating in a safe and sanitary condition. The hot water temperature in residents' bathrooms measured 119 degrees F. LPA observed a clorox cleaner kept unlocked in resident's bathroom. Staff removed the cleaner. Six (6) resident bedrooms were inspected. LPA observed full bedrails in resident #1 (R1) and resident#2 (R2); R1 and R2 are not receiving hospice care. LPA observed half bedrails in resident # 4 (R4) and resident #5 (R5). The Administrator stated the bed rails are utilized for fall prevention; However this is no documentation of physician's orders approving R4's and R5's bedrails. LPA observed staff utilizing part of R1's room area for facility storage use. The facility has posted in a common area, Ombudsman poster, Personal Rights, disaster evacuation plan and emergency telephone numbers. Food Service: Facility's (3) kitchen areas were maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. The facility has posted a weekly menu. In building #1, LPA observed an unlocked kitchen cabinet with cleaning supplies and disinfectants. LPA observed staff attempting to lock the cabinet; however the lock was not working properly. Staff removed the supplies and disinfectants and placed them in a locked medication room. Staff then fixed the locked that was not working properly. Medical Related Services : In building #2, LPA observed an unlocked medication closet were resident's medications were stored and accessible to residents in care. Staff locked the cabinet. Record Review: The facility has a disaster plan and infection control plan for review. Staff files were reviewed for health screening, personnel record (LIC501), criminal record clearances, job training and firstaid/CPR certification. Resident files were reviewed for admission's agreement, preplacement appraisals, personal rights and medical assessments. LPA observed R1's medication was placed in two (2) daily pillboxes. Administrator stated that the resident's spouse wants them to keep them in the pill box. LPA observed Resident #3 (R3's) AM medication from day 1 through day 11 was still in the bubble pack. The Administrator stated that the resident only wants to take the pill once a day; however this is no documentation of resident refusal and no documentation of staff contacting R3's physician of the refusal. The prescription label shows medication to be given twice daily. LPA also observed R3's was out one of their daily medication. The Administrator stated the medication should arrive later today or tomorrow. R3's physicians report/assessment (LIC602) shows resident takes insulin injection pen and uses a foley catheter. Administrator stated that the resident no longer utilizes these items. Interview with resident #3 reveals they are no longer using insulin injections and catheter. Administrator stated she will have an updated medical report conducted. LPA requested a staff schedule from the Administrator; a schedule showing staff hours was not available for review. During today's visit, Deficiencies were cited and technical advisories were issued in accordance with Title 22 of the California Code of Regulations. An exit interview was conducted where this report was discussed. Copies with appeal rights were provided to the Administrator at the conclusion of the visit.