Routine inspection·January 10, 2025

At approximately 1:30 PM, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to conduct a required 1-year annual inspection and were greeted by Staff 1 (S1). Alma Corsiga, Licensee was contacted via telephone and arrived approximately 30 minutes later. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care. Three (3) residents were away from the facility either at Day Program or on a community outing and one (1) resident was present during today's inspection. Facility has a hospice waiver for two (2), with no hospice residents currently in care, and is approved for all non-ambulatory residents. Licensee informed LPAs that Administrator has changed to Angel Dean. LPAs informed Licensee of the need to submit this request to Licensing. At approximately 2:00 PM, LPAs initiated a tour of the facility with Licensee and observed the following: Facility is a two story home, was a comfortable temperature, and passageways were free from obstructions. All residents live on the first floor of facility and Licensee's family lives on the second floor. Water temperatures in Residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of clean linens, paper products, and incontinent care briefs available to residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPAs advised Licensee to ensure the laundry room remains locked at all times when unattended since there are chemicals and cleaning supplies in the room. Facility has at least two days of perishable food and LPAs advised Licensee to increase the facility's supply of non-perishable foods to ensure facility can sustain all residents in care for 7 days in the event of an emergency. Additionally, LPAs observed at least five (5) instances of expired non-perishable foods, (see LIC809D). Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. LPAs observed the fence in the backyard on the left side of the facility to be damaged and falling down, (see LIC809D). LPAs advised Licensee to ensure the facility has a designated internet access device available for resident use to remain in compliance with regulation. Facility has internet available to residents in care and the phone was tested an operational. Continued on LIC809-C... Continued from LIC809... Facility's fire extinguisher was observed charged and was last serviced 2/2024. Smoke and Carbon Monoxide detectors were tested and were not operational during inspection, (see LIC809D).Facility conducts bi-annual disaster drills with the most recent drill was conducted 6/2024. LPAs advised Licensee that drills shall be conducted on a quarterly basis moving forward in order to remain in compliance with regulation. LPAs observed facility's infection control plan and emergency disaster plan which was last updated 12/2024. LPAs observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. Facility does not have a back up generator. Licensee provided LPAs with a copy of the facility's current liability insurance. At approximately 2:30 PM, LPAs reviewed four (4) staff files and four (4) resident files. Four (4) of four (4) staff files reviewed have all the required paperwork, proof of initial and current training hours completed, and proof of current First Aid and CPR training. One (1) of four (4) resident files reviewed have all the required paperwork. LPAs observed records for Resident 1 (R1) and Resident 2 (R2) to only have the admissions agreements present, (see LIC809D). Additionally, LPAs observed Resident 3 (R3) missing a signed and dated personal rights form in their record. Licensee states facility coordinates medical and dental visits for the residents and provides transportation to and from their appointments. At approximately 3:45 PM, LPAs reviewed medications and medication records. Resident 4 (R4) was observed with an expired medication currently being administered, R2 was observed with medications pre-poured into a weekly pill container and extra medications not recorded on the centrally stored medication destruction log, and R3 was observed with an unmarked baggy of pills in their medication administration bin which Licensee states were supposed to be destroyed (see LIC809D). Facility's P&I records and monies are not maintained in compliance with regulation as Licensee states that resident cash resources are kept in the facility's business bank account and the facility's logs have not been updated since 6/2024 for one resident and since 9/2024 for another resident, (see LIC809D). LPAs informed Licensee that resident funds shall never be co-mingled with facility funds. Required Change of Administrator Documents: LIC 308 (Designation of Facility Responsibility) Continued on LIC809C... Continued from LIC809C... Active and Current Administrator Certificate First Aid Certificate LIC 500 (Personnel Report) LIC 501 (Personnel Record) LIC 503 (Health Screening Report - personnel) Proof of Negative TB test LIC 9182 (Criminal Record Exemption Transfer Request) LIC 508 (Criminal Record Statement) Copy of Driver's License or Passport that is not expired Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations) Updated copies of the following documents are to be submitted to CCL within 30 days of this visit : LIC500 - Personnel Report (updated) LIC400 - Affidavit Regarding Resident Cash Resources LIC402 - Surety Bond Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights were given. Exit interview conducted with Licensee whose signature on form confirms receipt.