Routine inspection (multi-day)·November 22, 2024

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to continue a Required Annual Inspection which began on 11-21-2024. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Thea Capili. LPA then met with Co-Administrator May Paraiso, who arrived shortly after. According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. According to care records, staff interviews, and LPA observation: During this annual inspection, there were a total of six (6) residents in care [Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), Resident #5 (R5), and Resident #6 (R6)], of whom all were non-ambulatory, per their respective doctors. [See LIC811 Confidential Names list pages for a description of select person identifiers used in this report.] The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present. During this inspection, LPA interviewed multiple residents and multiple staff. LPA reviewed the care records for all residents and the personnel and training files for all staff. LPA also toured the interior and exterior of the facility, and inspected all common areas and bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. [CONTINUED ON LIC 809-C, 1 of 3] [CONTINUED FROM LIC 809] The facility’s ambient internal temperature was complaint at 74 F. Hot water at taps accessible to residents were also compliant in temperature: Kitchen Sink was 115.3 F, Bathroom #1 Sink was 105 F, and Bathroom #2 Sink was 110.8 F. Appliances to preserve perishable food were compliant in temperature: Kitchen Refrigerator was 39 F, and Kitchen Freezer was 0 F. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. No pools or bodies of water observed on the premises. The facility's fireplace was screened. There were no open-faced heaters accessible to residents. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility. Licensee presented proof of current business liability insurance. R1’s doctor wrote that they were sometimes “forgetful. R3’s doctor diagnosed them with Mild Cognitive Impairment (MCI). R2, R3, R5, and R6 were each diagnosed with Dementia, per their respective doctors. For all residents in care, their doctor determined that each required staff assistance with storing and taking their prescribed medications, and that each was not able to safely leave the facility unassisted. Inside the facility was a cabinet which contained centrally stored medications. Early on during LPA’s visit, the doors of this cabinet were closed but a caregiver’s keys were left inside the lock. Without the direct care staff noticing, LPA was able to open this cabinet and access the centrally stored medications. [LPA immediately secured/locked the cabinet, and the keys were returned to staff.] Inside the facility was a separate cabinet which contained over fifteen (15) bottles of cleaning chemicals, which would have been hazardous to residents diagnosed with Dementia. The doors to this cabinet were initially unlocked. Without the direct care staff noticing, LPA was able to open this cabinet and access the chemicals. [LPA immediately notified staff and with their help, relocked the cabinet.] In the facility’s backyard, LPA observed unlocked/accessible the following “tools and items that could constitute a danger to residents”: one (1) full-length pole saw with serrated metal blade, one (1) full-length scraper tool with sharp metal blade, three (3) full-length shovels with metal spades, one (1) half-length shovel with metal spade, and one (1) full-length bow rake tool with rigid metal teeth. [Facility staff immediately moved these tools to a locked area.] [CONTINUED ON LIC 809-C, 2 of 3] [CONTINUED FROM LIC 809-C, 1 of 3] During the visit, LPA observed, and manager interview confirmed: Licensee did not ensure the facility’s three (3) fire extinguishers had been professionally inspected and serviced within the last twelve (12) months, which was needed to remain in ongoing compliance with the facility’s prior-approved fire clearance. Also, Licensee did not ensure that a working “auditory device or other staff-alert feature to monitor exits” was present on two (2) of the four (4) exterior exit-doors which residents had access to (which is required when caring for persons with Dementia). During a review of client records, LPA observed, and manager interview confirmed: R4’s doctor wrote that on their LIC602 Physician’s Report (dated 06-08-2023) that they did not have Tuberculosis (TB). However, Licensee did not have written proof of a negative TB test result or chest X-ray for R4, which was required before R4 moved-in. [During the inspection, R4 did not show signs/symptoms, observable to the layperson, of active TB infection] For R2, R4, R5, and R6, Licensee did not ensure they had a LIC602 Physician’s Report (or equivalent Medical Assessment) updated within the last year, which was required for residents diagnosed with Dementia. For R1 through R6, Licensee did not complete a Functional Capabilities Assessment (or equivalent determination of the resident's ability to perform specified activities of daily living), as required. For R1 through R6, Licensee did not complete a Needs and Services/Care Plan (or equivalent “written record of care the resident will receive in the facility [and] the resident’s preferences regarding the services provided at the facility”), as required. There was also no evidence that Licensee held a care conference meeting with the respective responsible persons (RPs) for R1 through R6, within the last twelve (12) months, as was required. For R1 through R6, Licensee did not ensure their care records contained the name, address, and telephone number of a dentist to be called in an emergency, as required. For R1 through R6, Licensee did maintain a Personal Property Inventory, which was required to be completed with the resident and/or their representative at time of move-in. For R2, R3, R4, and R6, Licensee did not maintain a copy of the Resident’s Personal Rights, signed by the resident and/or their representative, in the resident’s record, as required. For R1 and R5, there was a copy of signed Resident’s Personal Rights, but the version of the form used was outdated/obsolete, and thus incomplete. For R1 through R6, Licensee did not maintain a Telecommunications Device Notification form, signed by the resident and/or their representative, as required. Also, Licensee did not maintain a record of body weights for R1 through R6. (Regulation required Licensee to “regularly observe” clients for changes in physical condition, to include “unusual weight gains or losses.”) [CONTINUED ON LIC 809-C, 3 of 3] [CONTINUED FROM LIC 809-C, 2 of 3] During a review of personnel and training records, LPA observed, and manager interview confirmed: Licensee did not maintain at the facility a personnel file on Staff #1 (S1), as required. Staff #2 (S2), who had worked at the facility since 2022, possessed an active background clearance from CCLD to work in care facilities, per a check of CCLD’s Guardian database. However, Licensee did not ensure that S2 was associated to the facility’s roster of staff, as required. Licensee did not ensure S2 and Staff #3 (S3) had a completed and signed Health Screening (or equivalent pre-employment physical), as required. Licensee did maintain proof that Staff #4 (S4) and Staff #5 (S5), both of whom provided direct care to residents, had current First Aid Training from a qualified agency, as required. Interview of S4 confirmed they were missing this training. R1, R3, and R4 were current hospice care patients. However, Licensee did not have proof that S1 through Staff #9 (S9) were trained by each residents’ hospice agency on the resident’s “current and ongoing needs,” as required. Licensee did not have proof that S1 through S9 had received training on the facility’s written Emergency Disaster Plan within the last year, as was required. Also, Licensee did not have proof that S1 through S9 had received training on Personal Protective Equipment (PPE) within the last year, as was required. Licensee did not have proof of completion of disaster drills within the last two (2) years. Interview of manager confirmed disaster drills were not conducted. (Regulation required Licensee to drill each shift at least once per quarter). Nineteen (19) deficiencies were cited per California Code of Regulations, Title 22, and three (3) deficiencies were cited per California Health and Safety Code (refer to the LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding a needed Hospice Exception Request for R1 (refer to the LIC9102-TV page). An exit interview was conducted with Administrator May Paraiso, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, the LIC811 Confidential Names List pages, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today's visit.