Routine inspection·March 8, 2024

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Designated Administrator (DA) Carmen Buno. LPA Rai observed 1 staff (S1) and 3 residents at the facility since 1 resident was out of the facility. At approximately 9:20am, LPA rang the doorbell and no one answered the door. At approximately 9:35am, the resident (R3) opened the door and stated there was no staff in the home and to wait for someone to come. At approximately 9:30am, staff (S1) opened the door and let LPA enter the facility. S1 stated the employee was newly hired and assisted residents with activities of daily living (ADLs) as a caregiver. S1 stated S1 was not fingerprinted and planned to go today 3/8/2024 to submit the application. Per interview with DA, S1 assisted DA with the residents and DA is aware S1 is not Criminal Background Cleared and DA understands staff who work with residents need to be Criminal Background Cleared before they start to work at the facilty. During visit, LPA Rai toured the inside and outside of the facility with staff (S2). When touring the outside area of the facility, the exits were cleared of obstruction. 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 a closet next to the front door which was unlocked and contained food supply and cleaning supplies. DA and S2 removed the cleaning supply items to the laundry room. LPA observed the cleaning supply and the laundry detergents located in the cabinets in the laundry room accessible to resident in care. LPA observed laundry detergent under the utility sink next to the laundry machine. At the time of visit, laundry machine was not in use. Continuation on LIC 802-C, Page 1 out of 3. Page 2 of 3. LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. LPA observed 2 out of 4 resident bed had half-side rails and residents were not under Hospice services. DA stated the residents do not have doctor's orders for the residents to use half-side rails and was not aware resident's need physician's order for bedrails. LPA reviewed resident's Admission Agreement and on page 22, the facility stated the procedure of obtaining physician's order for bedrails. LPA Rai observed prescription medication and over the counter (OTC) medication in 2 out of the 5 residents rooms. DA stated she was not aware of the medications in the resident's room. S2 stated R1 administered the medication themselves and the staff administer the medications for R2 but keep the medications in R2's room. LPA observed R2 medications accessible to residents in care. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 115.5 degrees F - 117.1 degrees F. The water temperature in the kitchen sink was 116.5 degrees F. The temperature of the facility was measured at 72 degrees F on the thermostat. Fire extinguisher was observed and inspected on 02/04/2024. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drill was conducted on 10/4/2023. Per DA and S2, Administrator conducted a disaster drill in January 2024 but could not locate the document. LPA Rai observed an Emergency and Disaster Plan binder which located all drill records for the past 2 years. LPA Rai reviewed facility records for 2 staff and 2 residents. 2 out of 2 staff files contained documents from when the building was licensed under a different license. DA stated the facility hired some of the staff from the previous license when the Department approved their license. DA stated they retained the old documents and placed them in the file. LPA Rai stated the facilty needs retain documents that are issued from the current Licensee and the previous documentation may not be appropriate. Page 3 of 3. R3's resident files did not contain Needs and Services Plan and R3 has a diagnosis of Dementia. R4's resident files did not contain a complete Needs and Services Plan dated 11/8/2022 which is not signed. R4's resident file did not contain LIC 613 Personal Rights. DA reviewed LIC 613 Personal Rights with R4 in his/her room during today's visit. LPA Rai reviewed resident medications and central stored medication records. A civil penalty is being assessed for the amount of $400 ($100 per day x 4 days = $500), for staff (S1) working at the facility without a Criminal Background clearance transfer. Please see LIC 421BG. Per DA, S1 worked at the facility on February 26, February 27, February 28th and March 8th 2024. Deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Designated Administrator (DA) Carmen Buno and a copy of the report was provided. Technical Violation and Technical Assistance was provided. Appeal Rights were provided.