Routine inspection·January 30, 2024

On January 30, 2024 at 9:16 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the unnanounced Annual 1-year required inspection. LPA Calandra was greeted by Manolito Torres, Caregiver at the door and explained the purpose of his visit. Administrator, Prosperidad Gonzales joined the visit later. LPA Calandra toured the physical plant. This is a 2-story building that consists of bedrooms and 2 bathrooms(1 for residents and 1 for staff). Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. The resident bathroom was observed to have the required grab bar and anti-skid mat. Fire extinguishers in the facility were observed to be fully charged and last checked on March 7, 2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature were within the required range. All bedrooms were sufficiently lit and had the required furniture. The backyard was clear from obstructions. No accessible bodies of water or hazards were observed. The facility is being maintained at a comfortable temperature of 70 degrees Fahrenheit. The facility's first aid kit was observed to be complete. The facility does not handle any cash resources at this time. LPA Calandra reviewed 4 resident records and 5 staff records. Documents missing include signed Consent Forms, Needs and Services Plans, LIC 602s, etc. All knives and sharp objects were observed to be locked and in-accessible to persons in care. All medications, soaps, and detergents were observed to be locked and in-accessible to persons in care. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility. LPA Calandra requested the following documents from the facility be sent via email or fax to the RO: -Administrator Certificates -Theft and Loss Policy -Liability Insurance -LIC 309-Administrative Organization -Control of Property -Designation of Facility Responsibility During the physical plant tour, LPA Calandra observed a resident who appeared to be bedridden. After an interview with the Licensee/Administrator and R1, LPA Calandra determined that this resident fits the definition of bedridden. LPA Calandra contacted support staff to request a copy of the facility's current fire clearance. The latest fire clearance does not state that bedridden persons can reside in the facility. LPA Calandra discussed with the Administrator that the facility is currently operating outside of their license and that the facility will be cited for this. Additionally, during an interview with the Licensee, LPA Calandra learned that the facility had a client on oxygen. LPA Calandra asked the Licensee if the fire department had been notified and was told they have not. During today's visit the facility was cited for accepting and retaining a bedridden resident without obtaining and maintaining appropriate fire clearance, not including in their plan of operations how the facility plans to care for bedridden residents, failure to have an emergency disaster plan which addresses fire safety precautions specific to evacuation of bedridden residents, staff records not including documentation of staff training related to the care of bedridden residents, and for the use of bed rails without a doctor's written order, and failing to provide on-the-job training to staff who care for residents with Dementia, and failure to complete a medical assessment, and reappraisal for residents on an annual basis. Technical violations were provided for failure to have a written request for acceptance or admittance to or retention in the facility, while receiving hospice services, failing to have an auditory device or other staff alert feature to monitor exits. A Type A violation was provided for failure to obtain fire clearance for bedridden resident. A Technical violation was provided for retaining a bedridden resident and not including additional information in the plan of operations. Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. The report was reviewed with Licensee/Administrator, Prosperidad Gonzales and a copy along with Appeal rights was left at the facility.