Routine inspection·January 16, 2025

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Staff Abijuan Burchell. During the visit, LPA observed 3 residents and 2 staff. LPA explained the purpose of the visit. Staff S1 contacted ADM at 2:02pm. LPA informed ADM, via phone call, that LPA was conducting their annual inspection. ADM stated he could not come to the facility and stated staff S1 could sign on his behalf. LPA toured the facility inside out with S1 which included the Living room, kitchen, dining room, 2 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. While touring the facility garage, LPA observed the door which leads to the garage does not have a locking mechanism. (Photograph was taken.) LPA observed the facility garage has an assortment of detergents and other cleaning liquids and sprays on the ground, accessible to residents in care. (Photographs were taken.) While touring the backyard, LPA observed a storage shed in the backyard. LPA asked S1 to open the storage shed. S1 informed LPA the storage shed does not have a lock. LPA observed inside the storage shed, a container of gasoline, paint and other tools. LPA opened container of gasoline and confirmed the container had gasoline liquid inside. (Photograph was taken.) Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area as locked and inaccessible to residents in care. Room temperature was at 76 degrees F, and hot water temperature was measured to range from 116-118 degrees F in both resident bathrooms. Page 1 Out of 3 Fire extinguisher was serviced in October 16, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by S1, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility conducted drills for the year 2024, for the following dates; August 30, 2024, May 31, 2024, and February 18, 2024. LPA asked S1 if a drill had been conducted From September 2024 - January 2025. S1 stated she believes a drill was conducted in November, but it wasn't written down. Staff was unable to produce documentation a drill had taken place in the 4th quarter of 2024. LPA reviewed facility records for 3 residents. LPA requested to review R1's needs and Services plan (ANS). Based on a review of R1's ANS, the form is blank, only containing the facility's information, the residents name, and dated December 2024. (Photographs were taken). S1 stated the facility was in the process of filling out R1's ANS. LPA reviewed R3's physician report dated, September 9, 2020. LPA requested to review R3's updated physicians report. Facility staff was unable to produce a copy of an updated physicians report or documentation showing the administrator contacted the residents responsible party to get an updated physicians report. LPA requested to review a copy of R3's needs and services plan. S1 stated ADM sent her a copy. S1 provided LPA with a Needs and Services plan for the facility, "Hearts and Minds Activity Center." LPA requested to review R4's physicians report and Needs and services Plan. S1 stated those are the forms the facility is still working on filling out. S1 stated R4 has not had a medical assessment yet. LPA was not provided a copy of R4's needs and services plan or physicians report. Page 2 Out of 3. LPA reviewed facility records for 3 staff. LPA requested to review staff S1's training for 2024. S1 stated she did not complete any training for 2024. LPA reviewed 3 resident medications and centrally stored medication records. While reviewing resident R1-R4's Centrally stored medication records, LPA observed R1,R2 & R4's Centrally stored medication log was not filled out. S1 stated they have not filled out their centrally stored medication record. LPA observed Resident R3's centrally stored medication record had several medications that were not listed and had incorrect information, such as the incorrect prescribing physician. (Photographs were taken.) The Department is issuing an immediate civil penalty of $250 for each repeat violation for the following deficiencies: 87309 Storage Space & Access (a), which was previously cited on January 25, 2024. 87463 Reappraisals (a), which was previously cited on January 25, 2024. HSC 1569.695(c), which was previously cited on January 25, 2024. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. This report was reviewed with Staff Abijuan Burchell and a copy of the report was provided. Appeal Rights was provided. Page 3 Out of 3. End of Report