Routine inspection·September 19, 2024

Licensing Program Analysts (LPAs) Marcella Tarin and LPA Christine Delores conducted an unannounced annual inspection visit at 9:45AM and met with General Manager (GM) Billy Mitchell and Health Services Director, Jocelyn Bailon. LPAs toured the facility inside and out with the General Manager to include the living room, dining room, kitchen, resident bedrooms, bathrooms, and exterior. Facility temperature maintained between 70 to 75 degrees F. Facility staff are fingerprint cleared and associated to facility. All emergency exits were observed to be clear of obstruction. LPAs toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 35 degrees F and freezer maintained at -5 degrees F. The exterior of the facility was also inspected. No toxins, chemicals or items that can pose a danger to residents observed. LPA Tarin toured 7 resident bedrooms. 7 out of 7 resident bedrooms had functioning lights, storage space for personal belongings, clean bedding, a chair, lamp and dresser/table. LPA measured hot water temperature, range of 106.7 to 115.7 degrees F for 7 out of 7 resident bathrooms. The facility was equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 6/30/2024. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed and drills are being conducted quarterly. The last fire drill was conducted on 6/30/2024. Facility has emergency disaster plan. LPA reviewed 7 residents Centrally Stored Medication and Destruction Records (CSMDR). LPA observed 7 out of 7 CSMDRs are complete with all medications accounted and documented. LPA observed the medication storage area was locked and inaccessible to residents in care. Please see LIC 809-C. LPA reviewed 5 out of 5 resident records. LPA observed 5 out of 5 resident records as complete to include a medical assessment, TB result, updated appraisal/needs and services plan, identification and emergency contact information, personal rights, and consent forms. LPA reviewed 6 out of 6 staff records. LPA observed 4 out of 6 records as complete to include fingerprint clearance, health screening, TB result, and personnel record. Staff (S1) and (S4) records were observed as incomplete. S1 file was not available for review by LPA. GM states corporate has the file and does not have the physical file in the facility. S1 does not have a health screening and TB result. GM states a plan to obtain a health screening and TB result. S4's file does not contain a health screening and TB result. GM states they have requested the health screening and TB result and are awaiting the documentation. 6 out of 6 staff records did not contain documentation for annual training. GM states he has the training records on file in an email and will email staff training records to LPA Tarin by morning of 9/20/2024. LPAs advised GM that all personnel records must be maintained at the facility and available for review by the licensing agency. During visit LPA obtained GM's administrator certificate and resume. Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809-. Exit interview was conducted with GM. This report was provided to GM and appeals rights were provided.