Routine inspection·January 3, 2025

On 1/3/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator, Alice Feng. The facility currently provides care for 14 residents, none of which are bedridden or receiving hospice services, or with a diagnosis of dementia. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located throughout the facility were found to be charged. Smoke detectors were present in each common room and resident bedroom with last fire safety inspection conducted in March 2024 ensuring all fire safety systems are in place. LPA was unable to determine if smoke alarms had interconnected carbon monoxide detectors. Administrator agrees to acquire and place a separate carbon monoxide detector in facility for safety measures. Technical Assistance issued. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. Cleaning supplies and other toxins are safely stored upon inspection. There was a supply of hygiene products and paper products available for residents. Resident's bedroom have lighting & appropriate furnishings and bedding items. Restrooms for resident use were equipped with non-slip mats, grab bars and kept in good condition. Upon spot review of medications, LPA found that the facility has documentation of resident prescriptions on file with medication counts in order. Continued onto LIC809-C LPA conducted a sample file review for residents and found that 3 out of 4 residents had signed documentation indicating that the service plans had been reviewed and agreed upon by both residents and case managers. However, upon review of records, LPA found that the Administrator had not been provided copies of the actual service plans. LPA confirmed that the assessments had been completed and the Administrator will be contacting each resident case managers on acquiring the full documents. Technical Assistance issued. Upon a sample review of 4 staff files LPA found that all caregiver staff have current 1st aid and CPR certification and health screening reports on file. During the visit, LPA and Administrator had discussed an incident that occurred approximately one month prior regarding a resident (R1) who had been sent out for medical check after staff observed R1 having difficulties ambulating. Administrator informed LPA of the changes observed in R1 during the past several months with no indications or statements from R1 of physical health concerns. LPA was informed that R1 is currently in the hospital and awaiting medical discharge. The Administrator immediately notified R1's case manager, conservator for mental health and R1's family. However, CCLD was not notified as Administrator explained the event was not a medical emergency or injury. LPA explained to Administrator the reporting requirements as the incident resulted in resident hospitalization. Administrator agrees to reconcile documentation by submitting an incident report of this event by POC date 1/4/2024. Technical Violation issued. Administrator has been in frequent contact with R1's case manager and has been visiting R1 in the medical center. R1 is currently receiving physical rehabilitation and awaiting discharge. LPA requested the following documents be sent to CCL by COB 1/17/2024: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan No deficiencies cited during today's visit.