Routine inspection·October 26, 2023

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required 1 - year annual inspection. Administrator (ADM), Elaine Yalung was called and states she was unable to meet LPA at the facility. LPA met with Lead Caregiver, Evelyn Yalung. During visit, LPA toured the facility with staff to include the living room, dining room, kitchen, resident bedrooms, staff bedroom, bathrooms, garage, and backyard. All fire exit routes were free and clear of obstruction. 3 staff present are fingerprint cleared and associated to the facility. Facility temperature maintained at 76 degrees Fahrenheit. Facility currently has 4 hospice care residents. (The facility is pending approval for an increase of hospice care residents as of 10/09/2023). 3 residents under hospice care observed with bed rails that extends half the length of the bed. 2 residents did not have a physician's order for half rails in their records. During visit, the 2 resident's hospice care nurse arrived to the facility to drop off their hospice care notes from this morning. Nurse states the residents are provided a physician's order for a "hospital bed", but the physician's order does not specify "half rails". Hospice nurse placed an order for "half rails" and is pending a final signature from the physician. Facility will obtain the order once completed. 1 resident under hospice care observed with full-length bed rails. LPA did not locate the resident's hospice care plan in the facility. ADM emailed resident's hospice care plan to LPA, but LPA did not locate an order for full-length bed rails in the hospice care plan. ADM called the hospice nurse who later sent the physician's order for full-length bed rails signed and dated on 10/26/2023. SEE LIC809-C. Facility's kitchen observed with at least 2 days worth of perishables and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 50 degrees Fahrenheit. ADM was advised. Freezer temperature maintained below 0 degrees Fahrenheit. Food items observed covered and labeled. Sharp objects, chemicals, and disinfectants observed locked. Resident bedrooms equipped with beds, clean linens, dressers, night stands, and adequate lighting. Bathroom supplied with hygiene products, grab bars, and paper supplies. Hot water temperature maintained at 140 degrees Fahrenheit. Facility was advised. LPA reviewed 5 resident records. 2 resident's (R1 - R2) physician's report was last updated in 2021. Both residents are diagnosed with Dementia. R1 - R2 did not have a TB result on file. 5 out of 5 resident's files contained an updated appraisal/needs and services plan, consent form, and personal rights form. LPA and staff reviewed 5 out of 5 resident's centrally stored medications and centrally stored medication records. LPA advised to ensure the centrally stored medication records are completely filled out and to log resident's over-the-counter medications. ADM was advised. LPA reviewed 3 staff records. All the staff records contains a 1st aid certification, fingerprint clearance, health screening, TB results, and job application. Staff are provided training on topics to include dementia care, postural support, and medication. LPA advised to input the training hours on the certificates for 2023. Facility has an infection control plan and PPE supplies. Staff are trained on infection control. Facility has an emergency disaster plan. Facility has extra batteries and flashlights. First aid kit observed complete with tweezers, scissors, bandages, gauze, and a manual. Staff conducted emergency disaster drills at least quarterly. Fire extinguisher last services on 08/10/2023. LPA observed the facility has smoke detectors that writes "smoke alarm" . ADM states the detectors are wired and a combination of a smoke alarm and carbon monoxide detector. ADM states they had a fire inspection this year and will follow-up with LPA Dolores regarding their fire inspection report. Documents were requested to include the facility's liability insurance. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed on the phone with Administrator, Elaine Yalung and Lead Caregiver, Evelyn Yalung and a copy of the report and appeal rights was provided.