Routine inspection·June 17, 2024

On 06/10/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced infection control annual inspection. LPA met with caregiver Lorna Torres and explained the purpose of today's visit. There is 1 staff present and 6 residents present. 5 of the residents are still in bed but one is awake and interacting freely in the facility. A second caregiver is on duty as well but is picking up resident medications per Lorna. LPA was allowed entry into the facility. This is a single level facility. Annual fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer adjacent to the stove top. Medications are also locked in the kitchen in a cabinet. Perishable and non-perishable food items are observed as in place. There are additional refrigerators and freezers in the garage areas which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed that there is one fire extinguisher in place in the dining room last inspected 03/28/2024, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational located in the garage area. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 107F. Shower floor uses non-skid mat when shower is in use. LPA observed all residents rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place. Continued on next page... Page 2 LPA reviewed 3 client files and also reviewed 3 staff files on this day. Per resident files reviewed they are incomplete and not current. Needs and appraisal plans are not completed as well as other items such as current physician reports as several are from when the resident was admitted to the facility. Per staff files reviewed, staff do not have current first aid cards on file. These discoveries pose a potential health and safety risk and a citation is issued. P&I is not handled by the facility. Client medications are inspected and are current including facility medication administration records. Administrator certificate is observed as expired on 12/23/2022 but has submitted the renewal but has not received the new license per licensee phone call made during today's visit. The following updated forms are requested to be submitted to CCLD by 06/24/2024 : • Copy of updated Administrator Certificate • LIC308 Designation of responsible staff person • LIC400 Affidavit Regarding Client/Resident Cash Resources • LIC610D Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property such as lease agreement with expiration date Citations issued on attached LIC809D. Report is reviewed with caregiver Lorna and a copy is provided.