Routine inspection·March 5, 2024

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Lead staff Elma Pacursa, S1. S1 contacted facility ADM and informed her about LPA's visit. ADM arrived shortly after. During the visit, LPA observed 6 residents and 3 staff. ADM informed LPA that she could not stay due to appointment. ADM stated S1 could sign on her behalf. As LPA approached the entrance of the home, LPA stepped on the wooden planks of the floor, directly next to the front door and two of them were loose and sinked. LPA showed ADM the sinking wooden planks. ADM stated she would remove them and fix it. As LPA entered the home, Staff S2 introduced him/herself. LPA checked the facility personnel report summary and staff S2 is not associated with the facility. LPA checked guardian and staff S2 is not associated with the facility. LPA reviewed facility LIC500, dated January 17, 2023. The form states S2 is an on call care giver since 2022 and is also a live in. LPA interviewed staff S2. S2 stated he/she is not a full time employee and is a reliever. S2 stated he/she worked today and last week. LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 110 degrees F in both resident bathrooms. Page 1 Out of 2. Fire extinguisher was serviced in July 20, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on November 10, 2023. LPA reviewed facility records for 3 staff. LPA reviewed 3 residents records. LPA requested to review weight records for residents R1-R3. S1 stated the facility does not have a weight record for residents. Based on a review of R2's physicians report, dated May 1, 2023, R2 has dementia. LPA reviewed resident R2's Needs and services plan, dated March 4, 2020. S1 stated the facility does not have an updated Needs and services plan for this year. LPA reviewed 3 resident medications and centrally stored medication records. While reviewing resident R3's medications, LPA observed that R3's centrally stored medication log stated medication #1 had a start date of 9/29/2023. LPA requested Staff S1 to count the medication. Medication #1 had a total of 36 pills. S1 stated she made a mistake and did not update the centrally stored medication log, when she got a new refill. LPA observed medication #2 had a start date of 12/5/2023, based on the centrally stored medication log. LPA requested S1 count the medication. Medication #2 had 25 pills. Further investigation showed that medication #2 had written on the bottom 12/31. S1 stated she made a mistake and did not update the centrally stored medication log with the correct information. LPA conducted interviews with 1 staff (S1) and 2 residents. Deficiencies cited during today's visit. This report was reviewed with Lead staff Elma Pacursa and a copy of the signed report was provided. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500) for S1 working and residing in the facility without association. Appeal rights were provided. Page 2 Out of 2.