Routine inspection·September 21, 2023

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Lead Caregiver, Lisa (Noveliza) Manzanilla and stated the purposed of today's visit. LPA Rai observed 2 staff in the facility, 3 residents sitting in living room. Lisa stated 1 resident is admitted to skilled nursing facility. LPA Rai spoke with Administrator (ADM) Jonathan Perez over the phone after completing inspection. LPA Rai observed 2 cameras in the facility. One camera is located in the office area of the dinning room facing the dining room and kitchen and another camera is located in the living room facing the resident's sitting area. ADM and S1 stated the cameras only record video and do not record 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 observed the emergency exit ramp on the left side of the facility, when facing the facility building. This emergency exit ramp connects two resident rooms to the backyard. The concrete connecting the backyard floor to the wooden ramp is lifted approximately 3 inches, creating an uneven surface. S1 stated the residents have two additional emergency exits from the room. LPA Rai spoke with ADM and ADM is currently working with 2 contractors to fix the concrete in front of the wooden ramp. ADM stated the tree next to the concrete has lifted the concrete slab and the contractors will repair the concrete. 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 secured areas for cleaning supplies and laundry detergents in the garage area. Continuation on LIC 809-C, Page 1 of 4. Page 2 of 4. During touring the resident rooms, 2 out of 3 resident beds had half side rails. LPA Rai reviewed resident records and 1 out of the 2 residents had a written order for the half side bed rails. LPA Rai reviewed R3's file and R3 did not have a written order from the physician for half side bed rails. LPA Rai observed camera inside the resident rooms facing the resident beds. LPA Rai spoke with the ADM and ADM stated the resident's families provided the baby monitors for night staff to oversee the resident's at night. ADM stated they can disconnect the cameras and notify the residents' families. LPA Rai observed the staff removing the cameras. LPA Rai reviewed 3 out of 3 resident files. LPA Rai reviewed R1's file and R1 has a dementia diagnosis and did not have an updated Physician's Report, LIC 602A, and the document on file was signed on 3/8/2018. R1 did not have an updated Appraisal/ Needs and Services Plan and the document on file was signed on 3/16/2018. LPA Rai reviewed R2's file and R2 has a dementia diagnosis and does not have an updated Physician's Report, LIC 602A, and the document on file was signed on 5/9/2022. R2 did have Appraisal/Needs and Services Plan dated 5/19/2022, but the document was not signed by Responsible Party nor Facility Representative. R2's file did not have an updated Appraisal Needs and Services Plan. R2's file did have an Admission Agreement document but the document was not filled out and it was not signed by Responsible Party or Facility Representative. LPA Rai reviewed R3's file and R3 has a dementia diagnosis and R3 did not have updated Physician's Report, LIC 602A. R3's file did have an Appraisal/Needs and Services Plan document but it was not filled out with information and the document was not signed by Responsible Party and Facility Representative. R3's file did not have an updated Appraisal/Needs and Services Plan. R3's file did have blank Resident's Rights document and it was not signed by Responsible Party or Facility's Representative. R3's file did have blank Functional Capability Assessment and it was not signed by Responsible Party or Facility Representative. LPA Rai did review R3's Physician's Report which stated resident has auditory issues and R3 uses a hearing aid. R3's file did have blank LIC 9158 Telecommunications Devise Notification and it was not signed by Responsible Party and Facility Representative. Page 3 of 4. LPA Rai reviewed resident medications and central stored medication records. LPA Rai and S1 counted the medications for R1. During a random review/audit of resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record. LPA Rai along with Staff (S1) counted the tablets from the medication bottles. LPA Rai reviewed R1's Centrally Stored Medication Records with the stored medications. LPA Rai reviewed R1's medication and 4 out of 10 medications prescribed to R1 was not given as prescribed by the doctor. R1's medication #2 were counted 31.5 tablets instead of 32 tablets. S1 was not aware why one tablet was halved and R1 does not have an order for medication to be administered in a half. R1's medication #6 was counted at 260 tablets when there should be 258 tablets in the bottle. LPA Rai and S1 counted medication #6 three times and counted 260 tablets all three times. LPA Rai and S1 reviewed the facility's Medication Administration Record (MAR) and medication has been accounted for each dose since the bottle was opened. S1 stated the staff might have signed off the medication when the poured the medication in the medication cup and R1 may have refused the medication and the staff did not record the refusal on the R1's MAR. R1's medication #7 was counted at 72 tablets instead of 71 tablets, which concluded there were 1 tablet extra and resident was not administered one dose of the medication. LPA Rai and S1 reviewed R1's MAR which stated the first dose was taken on 4/8/2023, but the Centrally Stored Medication Log stated the prescription bottle was opened 4/6/2023. S1 stated R1 was given the medication starting 4/6/2023 and the MAR is incorrect, S1 stated there needs to be two signatures for 4/6/2023 and 4/7/2023 since S1 administered the medications both days. R1's medication #10 were counted 43 tablets instead of 39 tablets, which concluded there were 4 extra tablets and resident was not administered 4 doses of the medication and staff did not record the refusal on R1's MAR. S1 stated R1's physician did not place any medications on hold and LPA Rai did not observe any MD orders in R1's file for a medication hold. S1 stated R1 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 R1 did not refuse any medications according to R1's MAR. Page 4 of 4. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. One Technical Violation Note was provided during today's visit. 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 Administrator (ADM) Jonathan Perez over the phone and went over today's report and deficiencies cited during today's visit. Administrator agreed and understood. Exit interview was conducted with Lead Caregiver, Lisa (Noveliza) Manzanilla. A copy of this report was provided to Lead Caregiver, Lisa (Noveliza) Manzanilla. Appeal Rights were provided.