Routine inspection·September 20, 2023

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Lead Caregiver (LC), Rose (Rosalia) Calungcagin and stated the purposed of today's visit. LC could not get a hold of Licensee Leilani Cortes and left a message. LPA Rai observed 3 staff in the facility, 4 residents sitting in living room, 1 resident sitting in the dining room, and 1 resident in the resident room. LPA Rai observed 3 cameras in the facility. One camera is located in the living room, one camera is located in the dining room and one camera is located in the kitchen S1 stated the cameras only record video and no audio. During visit, LPA Rai toured the inside and outside of the facility with Staff (S1). When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food. LPA Rai did not observe at least 7 days of nonperishable food. LPA Rai observed approximately 20 canned foods and approximately 5 boxes of various flour. LPA Rai observed an emergency food supply in the living room next to the TV, but the food supply box was open LPA Rai could not verify if the recorded pouches of food in the box were the correct number of pouches inside the box. Licensee (LC) Leilani Cortes stated she will follow up with the staff to ensure the emergency food supply box stays closed and ensure the facility maintains one week worth of non perishable foods which will be sufficient for 3 meals and 3 snacks for 6 residents for one week. Sharps and medications were locked in secured areas. LPA observed secured areas for cleaning supplies and laundry detergents in the garage area. LPA Rai observed a podium in the garage and LC clarified they do not use the podium and the garage area is used as activity room for the residents. LPA Rai observed swimm ing pool in the backyard is fenced and inaccessible to the residents. Continuation on LIC 809-C, Page 1 of 4. Page 2 of 4. During tour of the resident rooms, LPA Rai observed 6 out of the 6 beds have half bed side rails. S1 stated residents do not receive Hospice services. LPA Rai reviewed 6 resident files and did not observe written order from a physician for half bed side rails. LPA Rai observed oxygen tank in resident R6's room. S1 stated R6 is discharged from hospice services since yesterday 9/19/2023 and does not have home health services at this time. S1 stated R6 has dementia diagnosis and R6 is not mentally and physically capable of operating the equipment, R6 is not able to determine his/her need for oxygen, and R6 is not able to administer it him/herself. S1 stated R6 does not have an appropriately skilled professional performing oxygen administration. S1 stated R6 requires total care and R6 is bedridden not able to reposition his/herself in bed. LPA Rai notified S1 that total care is a prohibited condition and S1 stated R6 was on hospice services but was discharged from services yesterday 9/19/2023. S1 stated there are no assessments completed for R6 to go back to hospice services or initiate home health services. The facility bathroom had available soap, paper towels, and trash cans with lids. The shower had grab bars and non-skid mats. The water temperature in the bathroom sinks ranged from 105.1F-106.5F. The water temperature in the kitchen sink was 105.3F. Facility smoke detectors and carbon monoxide detectors were in working condition. 4 out of 4 resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai reviewed facility records for 6 residents. LPA observed 3 residents did not have an appraisal/needs and services plan since their admission date. LPA Rai observed 1 resident did not have a medical assessment completed, such as the LIC 602A Physician's Report, since their admission date. LPA Rai observed 3 out of 6 residents with dementia diagnosis did not have annual needs and services plan, last needs and services plan on file was completed in 2020. LPA Rai observed 4 out of 6 residents with dementia diagnosis did not have annual medical assessment completed, such as the LIC 602A Physician's Report, last medical assessment on file was completed in 2019, 2020, and 2021. LPA Rai did not observe TB test results for R3 in resident's file. Page 3 of 4. LPA Rai reviewed 4 of 6 resident's weight log. LPA Rai did not observed the weight record of R3 and R6. S1 stated R3 was recently admitted and did not have a weight log. Based on record review, R3 has been admitted to the facility for 3 months and did not have any recorded weight log. S1 and S3 weighed R3 during today's visit and initiated weight log. Based on LPA Rai's observation and S1's interview, R6 is bedridden was discharged from Hospice yesterday 9/19/2023. LPA Rai did not observe any Hospice notes or facility notes on resident's weight log. S1 stated Hospice sometimes measures R6's arm, but LPA Rai did not observe any progress notes mentioning resident's arm measurements. S1 could not located records with arm measurements. S1 could not locate a tape measurement in the facility. LPA Rai reviewed resident medications and central stored medication records. LPA Rai and S1 counted the medications for R2 and R5. LPA Rai reviewed R2's and R5's Centrally Stored Medication Records with the stored medications. During a random review/audit of resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record, 4 out of 7 medications prescribed to R2 was not given as prescribed by the doctor. LPA Rai along with Staff (S1) counted the tablets from the medication bottles. R2's medication #1 were counted 10 tablets instead of 0 tablets, since the medication bottle should have been empty if medication was administered according to the MD's prescription and order on the prescription bottle.R2's medication #2 were counted 140 tablets instead of 142, which concluded there were 2 medication pills missing from the prescription bottle. R2's medication #3 were counted 32 tablets instead of 34 tables, which concluded there were 2 medication pills missing from the prescription bottle. R2's medication #5 were counted 41 tablets, when there should have been 40 tablets, which concluded there were 1 tablets extra and resident was not given one dose of the medication. S1 stated R2's physician did not place any medications on hold and LPA Rai did not observe any MD orders in R2's file for a medication hold. S1 stated R2 was not admitted to the hospital or left the facility for long periods of time which would cause for resident to miss a dose of medication. S1 stated R2 did not refuse any medications. S1 stated S1 is a live-in staff and S1 is the only staff member who administered the medications to the resident. Page 4 of 4. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. 87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs. LPA Rai spoke with Licensee Leilani Cortes over the phone and went over today's report and deficiencies cited during today's visit. Administrator agreed and understood. LPA Rai went over Administrator expectations of the administrator being present in the facility at least 20 hours a week. Licensee Leilani Cortes is the administrator of this facility. Exit interview was conducted with Licensee, Leilani Cortes. A copy of this report was provided to Lead Caregiver, Rose (Rosalia) Calungcagin. Appeal Rights were provided.