Follow-up·October 30, 2024

Licensing Program Analysts ( LPAs) Steve Chang and Mita Partoza conducted an unannounced case management inspection visit and met with Administrator (ADM) Jean Jose. ADM stated that licensee is not in the facility is out of the country approximately beginning of July, 2024 and have not returned since then. ADM stated that there are currently 6 residents in the facility. 1 Out of 6 is at the hospital and 5 out 6 are present and resting in their room. 1 out of 6 is ambulatory, 2 of 6 are under hospice care. 3 out 6 are non-ambulatory. 1 out of 6 is in the hospital. LPAs stated the purpose of the visit is to conduct a case management visit ensure that facility is compliant with California Code of Regulation (CCR) Title 22 such as the condition of the physical plant, staffing requirement, the living condition of the resident, and if the garage is being used as a room to accommodate a resident. LPA toured the facility inside and outside with ADM such as living room, kitchen, dining room, 3 restrooms and 6 residents bedrooms. 6 of 6 resident's room are sanitary, organized and has sufficient storage. One of the resident's restroom sink drawer cabinet was not closing properly and can be a tripping hazard. Bedroom #6 at the end of the hallway has a broken window glass and is missing a window screen. S1 stated that there are window air conditioner system for each room. However R1 does not want the window air conditioner. S1 stated that the screen window will be re-installed. The facility is equipped with working smoke and carbon monoxide alarm system. The front yard and backyard were inspected. LPAs observed the following, at the front yard is a vehicle that is not operational covered by a gray tarp. S1 stated that the vehicle has been parked for a number years prior to her being employed at the facility, LPAs toured the facility garage and observed a sleeper couch inside and clothing items. S1 stated that the staff use the garage as their place to rest, while the licensee is out of the country. LPAs observed a functioning bathroom with shower inside the garage used by the staff. Page 1 of 2 LPA observed backyard has multiple storage, one storage was missing a door. There was piled household items that are no longer in use, a recliner that is no longer in used, 2 grills that are not used, a bucket of standing water, piled wood planks, a non operating refrigerator by the side of the building, medical equipment that are no longer in use are stored inside an open storage. The facility has emergency exit gates on both sides. on the right side the gate is not attached and not functional and another plank of wood was used to put weight on the half gate to prevent the gate from falling. The walkway is obstructed by garden chairs. The bank fence needs reinforcement and 3 planks are not secured properly. LPA reviewed facility record and found that the facility's last disaster training was done on 8/14/2024. Based on review of the facility file, the facility has a total of 5 staff. Based on record review there is a shortage of staff for both day and night shift. S1 stated that he/she is the day and nocturnal shift (NOC) shift and sleeps on the couch so that he/she can hear the resident when they push their pendant when assistance is needed. The LIC 500 does not reflect the true hours and days that staff are working. S1 stated that when other staff are on break he/she covers the two hour breaks between shift. LPA reviewed resident's records including but not limited to centrally stored medication and destruction record (CSMDR), physician's report and appraisal needs and services plan, and observed that 2 out of 6 are under hospice care, 4 out of 6 are complete and updated. LPA reviewed 2 staff records and observed records to be complete an updated, certificates are up to date, compliant with training current and up to date. Staff are fingerprint/criminal background cleared. Licensee did not notify the Community Care Licensing (CCL) of their absence to ensure that the facility has general supervision over the affairs, policies concerning it's operations to conform with regulations. Deficiencies are cited during today's visit based on California Code of Regulation CCR, Title 22 87303 (a) and 87411 (a). An exit interview was conducted with ADM Jean Jose and a copy of the report was provided. Page 2 of 2.