Post-licensing visit·June 3, 2024

On 06/03/2024 Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an post required inspection. LPA Martinez met with Asha Prasad and explained the purpose of the visit. LPA Martinez inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. Administrator holds current certificate. The facility has a total capacity of 136 residents, of which 8 may be bedridden. The facility has an approved hospice waiver for 15. There are currently 92 residents who reside at this facility. The LPA Martinez toured the facility with Asha Prasad on 06/03/2024 at 12:00 PM. LPA Martinez reviewed five resident files and five staff files. Five out five resident files were complete. Four out of 5 staff files did not have a first aid certificate. LPA Martinez conducted a medication audit review with staff 1 (S1). During the medication audit, witness 1 brought a morphine sulfate syringe that expires on 05/01/25. It was learned an unused morphine Sulfate syringe was left in resident 1's (R1) room. Moreover, a facility staff signed the medication administration record (MAR) indicating the medication was administered to R1. In addition, the narcotic log sheet was signed off indicating the morphine syringe was administered and updating the medication count number. Additionally, the last fire drill was on 12/29/2023, which should be conducted every three months for Dementia residents. Due to insufficient time, a continuation post licensing visit will be required. LPA Martinez will return at a later time and date to complete the post licensing visit. As a result of this post licensing visit, the facility is not in compliance with Title 22 Regulations, and deficiencies can be found on the 809D page. An exit interview was conducted, and a copy of this 809 report, 809D page, appeals rights, and 811 page were provided to the facility.