Routine inspection·September 5, 2024

Licensing Program Analysts (LPAs) Marcella Tarin and Christine Dolores conducted a required unannounced 1 year visit and met with Resident Care Supervisor (RCS), Lisa Lanford. During the visit LPAs toured the facility inside and out. LPAs toured the kitchen area. LPAs observed a perishable food supply of at least 2 days and a nonperishable food supply of 7 days. Refrigerator temperatures maintained at 35 degrees F. Freezer temperature maintained at -6 degrees F. LPAs toured the resident dining area. LPAs observed a wooden plank in the track of the sliding glass door obstructing the sliding glass door in the dining room. Sliding door leads out to front of facility. Licensee was advised to ensure all exit passageways are free and clear of obstruction. Licensee was advised to remove wooden plank in the track of the sliding glass door due to fire safety hazard. LPAs toured 6 resident rooms. LPAs observed 5 resident rooms (Rooms 1, 2, 3, 4, 5) to have half-bed rails. LPAs observed Rooms 1, 2, 4 and 5 had half-bed rails, and Room 2 had full bed rails. RCS obtained orders for 3 resident's half-rails. LPAs observed the physician's order for the full-bed rails. LPAs recorded bathroom water temperature 120 degrees F in all resident bathrooms. LPAs observed all resident bathrooms had functioning lights and available soap and paper towels. LPAs observed each resident room had available bedding and clothing storage areas. LPAs tested the carbon monoxide detector to be functioning properly. The fire extinguisher last serviced on 7/26/2024. LPAs reviewed 5 resident Centrally Stored Medication and Destruction Record (CSMDR). 5 out of 5 reviewed CSMDR were complete during visit. LPAs reviewed 5 out of 5 resident records to be complete. LPAs were unable to review fire drill logs. RCS states she believes the emergency drills are locked in the office, which RCS is unable to access. See LIC809C. LPAs observed 2 out of 5 staff files are missing health screening and TB result. RCS states files may be locked in the front office which RCS is unable to access. LPAs advised that all personnel files should be available to Licensing agency for reviewing. LPAs were unable to review the administrators file. RCS states the file is locked in the front office, which RCS is unable to access. 5 out of 5 staff obtained fingerprint clearance. 1 out 5 staff have First Aid certification. Annual staff training records were reviewed. Documents were requested to update the facility file: liability insurance, administrator certification. Deficiencies were cited per California Code of Regulations Title 22 see LIC809D. This report was reviewed with RCS Lisa Lanford and a copy of the report and appeal rights were provided.