Routine inspection·October 10, 2023

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1 year inspection. LPA met with Administrator, Aaron Coronel. ADM started at the facility on 09/15/2023 and states he is still working on getting the facility back in compliance. During visit, LPA toured the facility with ADM to include the entrance, living room, resident bedrooms, staff bedroom, bathroom, kitchen, dining room, garage, and backyard. LPA observed there was a shed in the backyard. ADM did not have a key to the shed, therefore, LPA was unable to observe the inside of the shed. All fire exit routes are free and clear of obstruction. Facility temperature maintained at 72 degrees Fahrenheit. Fire extinguisher last services on 06/16/2023. Facility has at least one carbon monoxide detector located in the kitchen. Facility has a fire alarm pull system. Staff state they have not had an inspection from the fire department. Upon entrance, LPA observed a sign-in sheet, masks, hand sanitizers, and COVID-19 related posters. Additional signs were observed to include resident's personal rights, emergency disaster plan, infection control plan, emergency contact numbers, and activities calendar. LPA entered 3 resident bedrooms which contains 2 beds in each room. All resident bedrooms contained a bed, dressers, closet space, clean linens, and lighting. LPA observed residents R4 and R5's bed contains full length bed rails. The physician's order on file states an order for "side rails". ADM will confirm with the physician if full-length bed rails are needed. R4 - R5 are not receiving hospice care services. ADM was informed that an exception request is needed if R4 - R5 requires full-length bed rails. Bathrooms equipped with toilet paper, soap, and hand washing sign. Shower equipped with a shower chair, non-slip mat, and grab bars. Hot water temperature maintained at 126 degrees Fahrenheit. SEE LIC809-C. Kitchen is supplied with 2 days worth of perishables and 7 days worth of non-perishable foods. Items in the refrigerator observed covered. Refrigerator temperature maintained at 38 degrees Fahrenheit. Freezer temperature maintained at -2 degrees Fahrenheit. Sharp objects, chemicals, and disinfectants observed locked. Medication cabinet located in the kitchen observed locked. Facility has emergency telephone numbers posted at the front door. Each residents files contains an emergency information face sheet. LPA observed a complete first aid kit. Facility has emergency lighting and extra batteries. Staff has not conducted and documented quarterly emergency disaster drills. ADM was advised. PPE supplies observed to include gowns, shields, gloves, masks, disinfectants, and hand sanitizer. LPA reviewed 4 resident records. 4 out of 4 resident records contained an admission agreement, physician's report, and TB result. R1 - R4's file contained an IPP. R1's IPP was last updated in 2020, R3's IPP was last updated in 2019, R4's IPP was last updated in 2021. ADM was advised. ADM is currently working on updating appraisal/needs and services plan. ADM states he can get them done by 10/20/2023. Residents who require a wheelchair does not have a weight record on file because the facility does not have the equipment to weigh residents in a wheelchair. Facility has collaborated with home health agency to obtain the weight record for residents in a wheelchair. 4 out of 4 residents centrally stored medication records and P&I money were reviewed. LPA observed each resident has a PRN medication log. LPA reviewed 4 staff files. Current staff obtains a first aid certification, fingerprint clearance, health screening, and TB result. ADM obtains a current Administrator Certificate. Staff training records were reviewed. LPA did not observe staff were provided an annual 20 hours of training to include topics about dementia, postural supports, restricted health conditions, and hospice care. The following documents were obtained: LIC-610E, LIC-9282, LIC-308, and liability insurance. ADM will email LPA the LIC-500 by 10/11/2023. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Aaron Coronel and a copy of the report and appeal rights were provided.