Routine inspection·May 21, 2024

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Cheryll Lagunilla. LPA Rai observed 3 staff and 5 residents at the facility. The facility has 5 elderly developmentally disabled residents who are overseen by San Andreas Regional Center. During visit, LPA Rai toured the inside and outside of the facility. 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 and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.1 degrees F - 114.1 degrees F. During tour, LPA Rai observed Clorox disinfecting wipes in multiple areas of the facility, such as the kitchen and resident room, which was accessible to residents at the facility. LPA Rai observed 2 resident which were non-ambulatory and were using a walker around the facility. LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai observed 2 out of 3 residents did not have a signed Appraisal/Needs and Services Plan by Licensee and Resident/Resident's Responsible Party on file. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. LPA Rai reviewed resident medications and central stored medication records for 3 residents. LPA Rai observed 1 out of 3 resident (R3) has medication discrepancies wherein 5 out of 7 medication tablets in the bottle did not match the Central Stored Medication Record. Medication #1 should have 52 tablets in the bottle, LPA and Staff S1 observed 58 tablets, which meant there were 6 extra tablets in the bottle. Medication #2 should have 187 tablets in the bottle, LPA and Staff S1 observed 196 tablets, which meant there were 9 extra tablets in the bottle. Medication #3 should have 65 tablets in the bottle, LPA and Staff S1 observed 44 tablets, which meant there were 12 extra tablets in the bottle. Medication #6 should have 47 tablets in the bottle, LPA and Staff S1 observed 58 tablets, which meant there were 11 extra tablets in the bottle. Medication #7 should have 30 tablets in the bottle, LPA and Staff S1 observed 43 tablets, which meant there were 13 extra tablets in the bottle. LPA and S1 reviewed R3's Medication Administration Record (MARs) and staff initialed each dose, stating the resident was administered the medication and resident was not away from the facility. Fire extinguisher was observed and inspected on 10/3/2023. Facility smoke detectors and carbon monoxide detector are in working condition. The last disaster drill was conducted on 4/18/2024. 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. Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Administrator (ADM) Cheryll Lagunilla and a copy of the report was provided. Appeal Rights were provided.