Routine inspection·October 23, 2023

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator (ADM) Lori Mohassel and Licensee (LIN) Zenebesh Ghebresellasie. LPA Rai stated the purposed of today's visit. LPA Rai observed 3 staff in the facility, 3 residents sitting in living room, 1 resident sitting in the dining room, and 2 residents in the resident's rooms. At this time there is one resident under Hospice services. During visit, LPA Rai toured the inside and outside of the facility with LIN and ADM. 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 secured areas for cleaning supplies and laundry detergents in the garage area. LPA Rai observed oxygen tank in resident R3's room. ADM stated R3 does not use oxygen tank and the oxygen supplier company will pick up the supplies from the resident's room. The facility bathroom had available soap, paper towels, and trash cans with lids. The shower had grab bars and non-skid mats. The water temperature in the bathroom sinks ranged from 105.6F-106.5F. Facility smoke detectors and carbon monoxide detectors were in working condition. 6 out of 6 re sident bedrooms had available bedding, drawers, and functioning lights. LPA Rai reviewed facility records for 3 residents. LPA observed 2 residents did not have a completed appraisal/needs and services plan since their admission date. ADM and LIN could not located a completed appraisal/needs and services plan. ADM and LIN stated they will follow up with the resident's responsible party to create an appraisal/needs and services plan. Continuation on LIC 809-C, Page 1 of 3. Page 2 of 3. Facility did not maintain a weight log for 6 out of the 6 residents. LPA Rai reminded ADM and LIN need to observe resident for changes and this includes weight loss and weight gain. ADM and LIN will initiate a weight log for the residents to observe changes such as unusual weight gains or losses. LIN stated the facility staff will initiate measurement of resident's arms or thigh's to monitor resident's weight loss and weight gain for residents that are not able to use the regular weight machine. LPA Rai reviewed resident medications and central stored medication records. LPA Rai, LIN and S1 counted the medications for R1-R3. During a random review/audit of resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record, 2 out of 5 medications prescribed to R1 was not given as prescribed by the doctor. LPA Rai along with LIN and S1 counted the tablets from the medication bottles. R1's medication #1 were counted 64 tablets instead of 61 tablets, which concluded there were 3 extra tablets in the bottle and medication was not administered according to the MD's prescription and order on the prescription bottle. R1's medication #4 were counted 67 tablets instead of 64, which concluded there were 3 extra tablets in the bottle. 1 out of 5 medications prescribed to R2 was not given as prescribed by the doctor. LPA Rai along with LIN and S1 counted the tablets from the medication bottles. R2's medication #3 were counted 58 tablets instead of 52 tablets, which concluded there were 6 extra tablets in the bottle and medication was not administered according to the MD's prescription and order on the prescription bottle. 2 out of 2 medications prescribed to R3 was not given as prescribed by the doctor. LPA Rai along with LIN and S1 counted the tablets from the medication bottles. R3's medication #1 were counted 42 tablets instead of 32 tablets, which concluded there were 10 extra tablets in the bottle and medication was not administered according to the MD's prescription and order on the prescription bottle. R3's medication #2 were counted 10 tablets instead the medication bottle being empty and medication was not administered according to the MD's prescription and order on the prescription bottle. LPA Rai review facility records for 3 staff. LPA Rai observed 3 staff members did not have first aid training on file. ADM and LIN stated the facility staff have not been first aid training by a agency such as American Red Cross and 3 out of 3 staff will enrolled to first aid training. ADM and LIN will submit the completed first aid training and or certification to LPA Rai once completed. Page 3 of 3. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. 87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs. Exit interview was conducted with Administrator Lori Mohassel and Licensee Zenebesh Ghebresellasie and they both agreed and understood the deficiencies and the Plan of Correction for each citation. A copy of this report and Appeal Rights were provided.