Follow-up·April 23, 2025

On 4/23/2025 LIcensing Program Analyst (LPA) Santino Fortes and Licensing Program Manager (LPM) Romeo Manzano made an unannounced visit to open a Personal rights complaint with ADM Aaron Coronel. During visit there were 5 staff and 6 residents observed. During inspection visit, LPA and LPM arrived at the facility at 8:15am and met with 3 staff (S1-S3) in the dining/kitchen area. Five residents (R1-R5) were observed in the living room watching TV with Staff(S4). Staff stated breakfast service had just finished. LPA/LPM met with R6 at approximately 9am. While LPA and LPM were in the kitchen/dining area, deficiencies were observed and being cited during today's visit, see LIC809-D. The following deficiencies were observed as follows: Resident restrained in wheelchair by a strap. Medications are found accessible in a brown observed on top of an office table (against the wall on the left facing the street) in the main dining room accessible to residents in care. Staff S1-S3 stated that it belongs to 4 residents, R1 to R4. Staff stated that the medications were received last week and have not been logged to the Centrally Stored Medication form for May 2025. Staff were aware that medication has to be locked but when asked why medications were on top of the table unlocked, they were not able to provide an answer. Staff were not administering medication during LPA/LPMs arrival or visit at the facility. LPA/LPM observed that the centrally stored medication cabinet next to the coffee machine/stove was unlocked. Staff/ADM agreed that medication cabinet must be locked at all times. LPA/LPM also provided guidance of the importance of keeping medication inaccessible residents. LPM provided guidance Title 22, Code Section 80075 Continuation on page, 2 of 2 (LIC809 C) A defrosted meat (pork chops) was observed sitting on top of the fire place brick left overnight since 7pm (4/22) per S1 to S3. Staff stated that it belongs to Staff (S5) The facility serves residents with developmental disabilities, 1 of which has a behavior of consuming anything that could potentially a choking hazard (R1) LPA/LPM also provided guidance in the importance of food handling and storage. LPM provided guidance Title 22, Code Section 80076 . During LPA/LPMs tour of the facility, R1 was observed in the living room area while seated on a wheelchair with a gait belt 'tied' around his/her waist. Staff and ADM state that R1 and R2 requires a seat belt to prevent them from sliding or falling. R1 and R2 does not have the ability and capacity to unlocked belt in case of an emergency. On the other hand, staff also stated that R2 also requires a seat belt when in wheelchair. LPA/LPM observed that R2 also utilized gait belt (blue in color). ADM stated gait belts were given to them by a physical therapist to help residents with ambulation but not to utilized as a seat belt. There are no physician's order on residents' file to utilize gait belt as a seat belt. LPM provided guidance Title 22, Code Section 80072 During interview with ADM regarding his work schedule, ADM stated that he visits or monitor facility five (5) days week from 1:00PM to 4:00PM. LPA/LPM also discussed about the importance of ADM's physical presence in the facility at least 20 hours a week during business hours, Monday to Friday, 8:00AM to 5PM. ADM also oversees another RCFE. LPA/LPM informed ADM to submit an updated LIC500 Personnel Summary to CCL by close of business on 4/25/25. ADM is also advised to call caseload LPA and/or Desk Duty Officer, if needed. LPA/LPM also conducted a random review of residents' files. LPA/LPM also suggested that Appraisal Needs and Services need to be accurate in line with residents' IPP (Individual Program Plan) and kept up to date with resident behaviors not in the IPP. ADM agreed and understood. LPA also discussed about CCLD's Technical Support Program (TSP). LPA informed ADM that TSP is voluntarily but it will beneficial for keep facility in compliance with Title 22 regulations and can be accessed on the CCLD website. The following deficiencies were cited per CA Code of Regulations Title 22- refer LIC809-D. Appeal Rights information were provided and discussed with ADM