Routine inspection (multi-day)·February 22, 2024

This is a continuation of the required annual inspection done on 2/14/2024. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced continuation visit for the required annual inspection and met with administrator/house manager (ADM/HM) Randi Cabrera. Current census during today's visit is 20 residents 1 out of 20 is in rehabilitation, and 19 staff. LPA observed that the kitchen has a commercial grade gas stove with griddle and range hood. LPA observed that the range hood accumulated grease and grime that could pose imminent danger to persons in care. A used paper towel was observed stuck between the vent hood and the cabinet on the top left side. A used paper towel was placed on the griddle left bottom corner (photos were taken). Water temperatures for the bathroom and the kitchen was measured and ranges from 105 degrees Fahrenheit to 120 degrees Fahrenheit. During inspection of the facility, LPA observed that the conference room had an accordion door, behind the accordion door are facility’s decorating supplies (Christmas decors), 2 oxygen tanks, some furniture, and unused wheelchairs. The items in the room obstructed a designated emergency exit door. LPA observed a recliner upon exiting the door from the conference room, which obstructs the access to the walkway. LPA toured the residents’ and observed that emergency exits from the resident's room are clear from any obstructions, sliding doors are working and door alarms are in good working condition. LPA observed that residents’ rooms and common areas are clean and well maintained. All bathrooms have anti-skid mat and grab bars, sufficient supply of toilet rolls and paper towels. Resident rooms have ample storage, sufficient area for visiting families and clean beddings. Walkways inside the facility is clean and free from obstructions. continued to page 2 LIC 809C Continued from Page 1 - LIC 809 page 2 of 3 While inspecting the exterior perimeter and the backyard LPA observed a gazebo near the maintenance shed with tools that are in the open and can easily be accessed and poses imminent danger to persons in care. From the kitchen exit to the exterior, LPA observed a garbage dumpster, a wheel burrow and asphalt compactor obstructing the walkway and gate towards the front exterior of the facility and designated as an emergency exit, LPA reviewed 5 resident records herein referred to as R1 to R5, and their centrally stored medication and destruction record (CSMDR). LPA observed that R1 has two expired medication that was not discarded and noted on the destruction record. R3 has medication that was not listed on the CSMDR. LPA reviewed the 5 staff record, herein referred to as S1 to S5 and found training and personnel record updated. The following deficiencies were cited based on the California Code of Regulations (CCR) Title 22. Deficiencies were observed on 2/14/2024 inspection and today's visit. (87303)(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors . 80087(d) Buildings and Grounds- All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. 87705 Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). continued to page 3 LIC 809C Continued from page 2 page 3 of 3 Deficiencies continued. 87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (D)Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). Any on-the-job training provided for the requirements in Section 87411(d)(4) may also count towards the requirement in this subsection. An exit interview was conducted with administrator/house manager Randi Cabrera and a copy of this report and appeals right was provided.