Routine inspection·January 30, 2024

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's required - 1 year annual inspection. LPA met with Designated Administrator, Justina Nicholas and Licensee, Amparo Garcia. During visit, LPA toured the facility with Designated Administrator, Justina Nicholas to include the dining room, kitchen, living room, resident rooms, bathrooms, staff room, garage, and backyard. All fire exit routes were free and clear of obstruction. All staff present are fingerprint cleared and associated to the facility. Facility temperature maintained at 71 degrees Fahrenheit. Fire extinguisher last serviced on 03/25/2023. LPA did not observe an operable carbon monoxide detector present. During visit, Licensee left the facility to purchase a carbon monoxide detector and installed the device during visit. Posters observed at the entrance to include an 8x10 complaint poster sign, ombudsman poster, COVID-19 related posters, and personal rights. Kitchen refrigerator maintained at 48 degrees Fahrenheit. Licensee was advised. Freezer maintained at 0 degrees Fahrenheit. Medications, sharp objects, chemicals and disinfectants observed locked. Resident bedrooms equipped with beds, linens, adequate lighting, chair, night stands, and dressers. 3 residents observed with half bed rails. LPA observed a physician's order for 3 out of 3 residents. 1 resident observed using an oxygen concentrator. The resident's file contains a physician's order. Licensee was advised to place an "oxygen in use" next to the residents bedroom. LPA observed an oxygen in use sign was posted at the front door. SEE LIC809-C. Bathroom supplied with hygiene products, paper supplies, lidded trash bins, and non-slid mats. LPA observed the hot water temperature in room #4 to be maintained at 109 degrees Fahrenheit. LPA observed the facility's hot water pressure for the sink and shower was very low in the bathroom located in the hallway. LPA observed that bathroom's hot water temperature takes more than 5 minutes to heat up. LPA measured the hot water temperature to be maintained at 100 degrees Fahrenheit. LPA observed the hot water pressure in room #1 was also very low. LPA observed the hot water temperature in that room also takes more than 5 minutes to heat up. LPA observed the hot water temperature in Room #1 to be maintained at 100 degrees Fahrenheit. Licensee states awareness of the issues with the facility's hot water temperature and hot water pressure. Licensee states they started having issues with the water in summer of 2023. Licensee states when the residents requests for warmer water for their baths, they'd boil water to create warmer water. Licensee was advised. LPA reviewed 3 residents (R1 - R3)'s records to include an admission agreement, physician's report, TB result, updated appraisal/needs and services plan, emergency identification form, safeguard of personal properties, personal rights, and centrally stored medication records. LPA reviewed 3 staff (S1 - S3) records. S1 - S3 files contains an updated 1st aid certification, health screening, TB results, and employee rights. During visit, the facility was unable to produce the staff annual training documentation to include annual training on dementia care, postural supports, and restricted health conditions. Licensee states the staff has been provided annual training, however, the training documentation is located in another location. The facility showed LPA staff training on hospice care which equaled 4 hours of training. Licensee was advised. Facility staff are trained on infection control practices. Facility conducts emergency drills quarterly. The last emergency drill conducted was dated in December 2023. Facility has an updated emergency disaster plan. Facility has a first aid kit. Facility has extra flashlights. Deficiencies are being cited per California Code of Regulations, Title 22. SEE LIC809-D. Advisory notes provided. This report was reviewed with Licensee, Amparo Garcia and a copy of the report and appeal rights were provided.