Routine inspection·August 27, 2024

Licensing Program Analysts (LPAs) Marcella Tarin and Christine Dolores conducted a required unannounced 1 year visit and met with Administrator Stephanie Means. During the visit LPAs toured the facility inside and out. LPAs toured the kitchen area. LPAs observed a perishable food supply of at least 2 days and a nonperishable food supply of 7 days. LPAs observed the kitchen is supervised by staff which contains sharp objects, chemical disinfectants,and medications. Refrigerator temperatures maintained between 42 and 52 degrees F. Administrator was advised. Freezer temperature maintained at 0 degrees F. LPAs toured 10 resident rooms. LPAs recorded bathroom water temperature 108 degrees Fahrenheit in all 3 resident bathrooms. Hot water temperature next to room #1 maintained at 108 degrees F. The bathroom had functioning lights and available soap and paper towels. LPAs toured the bathrooms in each bedroom and found them to have working lights, available soap and paper towels. LPAs toured 10 resident bedrooms. Each room had working lights, and available bedding and clothing storage areas. LPAs observed 2 resident (Room 4 and Room 7) sliding door exits contained a pole and wooden plank that obstructed the opening of the sliding door. LPAs observed hygiene items on a dresser in Room 1. Based on record review, the Dementia resident is at risk if allowed access to hygiene items. LPAs tested the carbon monoxide detector to be functioning properly. The fire extinguisher last serviced on 1/5/2024. LPAs reviewed 5 resident files. It was observed that 5 residents Appraisal Needs and Services Plan were updated but did not contain signatures from the resident and responsible parties. LPAs observed that 5 Centrally Stored Medication and Destruction Record (CSMDR) were not maintained as multiple resident’s medications were not part of the CSMDR and did not contain a start date. 1 resident file did not contain a Physician’s Report. 2 residents did not contain an order for half-bed rails. See LIC809C. LPAs reviewed 5 staff files. It was observed that 5 staff files did not contain 10 hours of initial and/or 20 hours of annual training on topics covered in Section 87707. 5 out of 5 staff do not have CPR and First Aid certification. LPAs observed 2 staff scheduled during visit did not have CPR and First Aid certification. 5 out of 5 staff obtains fingerprint clearance. Facility has emergency disaster plan. LPAs advised to update the emergency disaster plan. Facility is not conducting emergency drills quarterly. LPAs observed flashlights in resident bedrooms. Facility does not have a written Infection Control Plan. Administrator was advised. Posters observed to include personal rights, ombudsman, facility license. LPAs did not observe the licensing complaint poster. Documents were requested by 8/30/2024 to include Infection Control Plan, updated Emergency Disaster Plan, Liability Insurance, Administrator Certificates. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809Ds. This report was reviewed with Administrator Stephanie Means and a copy of the report and Appeal Rights were provided