Routine inspection·October 16, 2023

On 10/16/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA was greeted by staff member (SM), Shamima Ali and explained the purpose of the visit. LPA asked that SM Ali call the Facility Designated Administrator (FDA), Maybelyn Ugale, and inform her that CCL was present at this time. Shortly after, LPA met with FDA Ugale and explained the purpose of the visit. There were two other staff members present at the facility, Cathleen Maghinay and Esterlita Chua. This facility is licensed to serve 6 residents who are 60 or older. 6 out 6 residents may be non-ambulatory. This facility also holds a Dementia Plan on file and has a hospice waiver for 2. Upon arrival at the facility, it was found that S1 was not currently associated to the facility. LPA asked to review staff and resident files. LPA was informed that staff did not know where files were, however, the facility administrator would be able to find the files when she arrives at the facility. LPA informed the facility that files shall be readily available upon request. LPA reviewed 3 resident files. 3 out of 3 resident files were observed not to have a current Appraisal form and did not have a Pre-Appraisal. 1 out 3 resident files did not have a current physicians report on file. LPA reviewed 3 staff files. 3 out 3 staff files were observed to be incomplete. Upon reviewing facility files, LPA observed FDA Ugale take several sharps from an open drawer and place them into a locked cabinet. The current administrator does not have a current active administrator certificate, however, the administrator has provided the department the proper renewal forms prior to their expiration date on 09/17/2023. The department reviewed a payment on 09/08/2023. A tour of the facility was conducted. A tour of the kitchen was conducted. LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply at this time. Knives were locked and made inaccessible in a separate closet away from the kitchen at this time. A fire extinguisher located in the kitchen was observed to be last serviced on 06/15/2023 by Armor Fire Inc and is in compliance at this time. Smoke detectors and carbon monoxide was observed to be in good repair. Medication was observed to be in a locked cabinet near the kitchen. Along with the administrator, LPA reviewed and compared resident medication to medication dispensing logs. A tour of 3 resident bedrooms were conducted. LPA observed that in 2 out 3 resident bedrooms did not have a chest of drawers sufficient to meet the resident's needs. A tour of a staff bedroom was also conducted. A tour of 2 resident bathrooms were conducted. Hot water temperature was taken to ensure that it was dispensed at the correct temperature at this time. LPA osberved water damage on the corner of the baseboard near the shower. Additionally, scuffs from the resident's belongings were along the walls. A linen closet was identified. Linen was observed to be in sufficient for residents in care. A tour of the garage was conducted. Washer and dryer were identified. Toxins, laundry detergent and other cleaning supplies were observed to be locked and made inaccessible. A tour of the yard was conducted. Perimeter fence and gates were observed to be in good repair with no hazards present. Based on the observations made on this visit, an immediate civil penalty of $500 was assessed for a violation of Section 80019(e)(2). This civil penalty was based on criminal record clearance transfer violation. The Licensee stated that S1 and S2 was working prior to obtaining her criminal record clearance transfer and has not done the paperwork prior to working at this facility. As a result of this visit, the following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. An exit interview was conducted. A copy of the 809, 809-C, 809-D, LIC421BG and appeal rights were printed and a copy was given to the facility designated Administrator, Maybelyn Magsayo-Ugale. The licensee was informed that a failure to correct any deficiencies by plan of correction due date(s) may result in civil penalties.