Routine inspection (multi-day)·July 25, 2024

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced continuation of the annual visit and met with Lead Staff, Irish Samantha Sinio. LPA Rai spoke with Licensee (LIC) Cindy Chen and Administrator (ADM) Donna Lagman and stated the purpose of today's visit. Both LIC and ADM informed LPA Rai over the phone they will not be present at the facility during todays visit. LPA Rai observed 4 staff, including Lead Staff and 4 residents at the facility. 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 observed three locked storage unit which was used as storage and not habitual space. LPA Rai observed the laundry machine in the backyard and observed 2 laundry detergents and 5 gallons of paint unlocked and accessible to the residents Lead Staff removed the items and locked them in one of the storage units. LPA Rai observed 1 resident smoking in the backyard who has neurocognitive disorder and was not supervised. 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. LPA Rai toured 6 bedrooms, out of which 4 bedrooms are occupied by residents and 2 bedrooms are occupied by staff. The resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai observed 2 out of 4 resident had half-bed rails attached to the resident's bed. Lead Staff stated the residents do not have signed written physician's order for residents to use half-bed rails for mobility. Lead Staff confirmed the 2 residents are not under Hospice or Home Health services. LPA Rai toured the garage and observed a sofa with blankets and rack of cloths hanging over the soda. Lead Staff states the bed is for lounging for staff and the garage is not used as a bedroom for any person. Continuation on LIC 809-C, Page 1 of 3. Page 2 of 3. LPA Rai observed 3 facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.4 degrees F - 111.4 degrees F. LPA Rai observed the third bathroom located in resident room #5 was not disclosed on the facility sketch. LPA Rai spoke with ADM and LIC regarding the third bathroom in resident room #5 and they both stated the bathroom has been part of the facility since the facility received the license and the facility had not made modification to the physical plant since obtaining the license. LIC stated she will reach out to the City of San Jose and send an updated Facility Sketch to the Department. LPA Rai observed yellow stains on the toilet seat and toilet bowl in the bathroom located in resident room #5. LPA Rai observed dark brown/black stains on the floor near the base of the toilet. LPA Rai observed resident occupying resident room #5 smoking in the backyard. LPA Rai asked Lead Staff regarding the yellow and dark brown/black stains and Lead Staff stated they attempted to clean the stains in the past but were not successful. Fire extinguisher was observed and inspected on 01/05/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. Per review of the records, the last disaster drill was conducted on 01/24/2024 Lead Staff confirmed the facility ADM did not conduct a disaster drill after 01/24/2024. LPA Rai discussed disaster needs to be conducted quarterly according to Title 22 regulations. LPA Rai reviewed resident medications and central stored medication records. LPA Rai reviewed R1's medication with Lead Staff. During observation of R1's medication to R1's Medication Administration Record (MAR), Lead Staff noticed R1's medication #1 did not have medication tablets in the medication bottle. Lead Staff stated they did not refill medication #1 and medication was not available at the facility. During visit, LPA Rai informed Lead Staff to contact the pharmacy to ensure resident's medication is available for pick up. Lead Staff stated to pick up medication on resident's behalf. During review of resident's Centrally Stored Medication Log/Record for all 5 residents and Lead Staff stated to misplaced the documents. Page 3 of 3. During previous visit on 7/12/2024, LPA Rai reviewed staff records, LPA Rai observed the staff records did not contain SOC 341A Statement Acknowledging Requirement To Report Suspected Abuse of Dependent Adults and Elders. ADM was present during visit on 7/12/2024 and when asked, ADM stated "was not aware about the staff signing the document". LPA Rai referred ADM to W&IC 15655 wherein the facility shall provide to all staff being trained a written copy of the reporting requirements and a written notification of the staff's confidentiality rights. ADM stated agreed and understood. 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, such as administer medication to residents in care. During audit of the medication, R1 did not have medication which is required to be administered today during bedtime and Lead Staff stated medication can be picked up tomorrow, indicating the medication will be missed today due to medication not available at the facility. After LPA Rai discussed the importance of following physician's orders and During visit, LPA Rai spoke with Licensee/Corporation's President & Secretary (LIC) Cindy Song Chen and Administrator/Corporation's Treasurer (ADM) Donna Lagman. Both LIC and ADM were not available to be present at the facility and informed LPA Rai of the same during telephone conversation . In order to exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves , as discussed in the past, both Licensee and Administrator have to be available and present at the facility 20 hours a week, Monday through Friday 8:00am - 5:00pm. LIC and ADM to submit an updated LIC 500 to reflect the hours of both individuals present at the facility during Monday - Friday. Deficiencies were cited per California Code of Regulations, Title 22 during today's visit, please see LIC 809-D. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Lead Staff, Irish Samantha Sinio and a copy of the report was provided. LPA Rai reviewed this report over the phone with Administrator, Donna Lagman. Appeal Rights were provided.