Routine inspection·January 11, 2024

On January 11, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:04 AM to conduct an unannounced Annual 1-year required inspection. LPA Calandra met with Laura Richardson, Program Director. Faimfili Howard, Executive Director arrived later and joined the visit. LPA Calandra toured the physical plant. This is a 3-story building that consists of 79 rooms and 79 bathrooms. Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and last checked on July 6, 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 was 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's first aid was observed to be complete. The facility does not handle any cash resources at this time. LPA Calandra received Consolidated Emergency Response/Contingency Plan and Floor plans. 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: -Job description/Personnel policies/on-the-job training -Fire Clearance -Health Screening Reports-Facility Personnel(LIC 503) -Plan of Operation -Plan for Incidental Medical and Dental Care -Qualifications of Administrator-Admin Certificate -Affidavit Regarding Client/Resident Cash Resources (LIC 400) During the tour of the physical plant, LPA observed S1 sitting on a bench in the hallway of Assisted Living, Floor 2. LPA asked staff member, their name, and S1 stated their name. LPA checked Facility Personnel Summary Report and could not find a staff member listed with that name. During a tour of the Assisted Living dining room, LPA stopped and spoke with S2 and asked S2 their name. S2 stated their name and LPA looked at the Facility Personnel Summary Report but again could not find anyone listed. LPA then called the RO and asked support staff to look up both staff. Support staff could not find S1 associated to the facility and S2 does not have criminal record/fingerprint clearance. LPA spoke to Executive Director about S1 and S2 and explained that until S2 has fingerprint/criminal record clearance, they cannot work. LPA explained that civil penalties would be assessed for both deficiencies. During today's visit a Civil Penalty of $1,000 was assessed for failure to ensure all individuals subject to a criminal record review were approved for a transfer of a criminal record exemption, as specified in Section 87355 and failure to obtain a California clearance or a criminal record exemption as required by the Department. Civil Penalty is $100 a day per staff member (2x) for the period of 1/6/2024-1/11/2024. The Annual will be completed at a later date. 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 Executive Director, Fili Howard and a copy along with Appeal rights were left at the facility.