Routine inspection·May 13, 2024

At approximately 9:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a 1-Year Required Visit and met with Staff Members Julie De Jesus and Frank Oboza. Licensee/Administrator, Rose Marie B. Devera was contacted and arrived during visit at approximately 10:15AM. Facility is a Licensed Residential Care Facility for the Elderly (RCFE) and serves residents with dementia. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 individuals. Upon arrival, LPA was informed that there were 5 residents in care and 3 staff members on-site. At approximately 9:50 AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility with staff members and Licensee/Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature. Carbon monoxide and smoke detectors were tested and found to be operational. Exits were observed as free from obstruction with the exception of one emergency exit in a shared resident room where a walker and commode were placed in front of the exit. LPA advised licensee per regulation, these exits are to be maintained free from obstruction. Licensee removed the items immediately. Facility's auditory signal was observed inactivated at facility entrance and inoperable in resident room on the sliding glass door emergency exit. Licensee had staff correct this during visit. Facility had emergency lighting. Facility is a 1 story building with 5 resident bedrooms, 1 staff bedroom, 2 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of perishable foods as required by Title 22 Regulations, but both canned and dried non-perishable food items were observed by LPA to be expired. Licensee threw them away immediately and ordered more non-perishable foods during inspection. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. LPA observed hand towels in the common resident restroom and advised Licensee that only paper products are in compliance with regulation. Licensee removed the towels immediately. Toxins were observed to be stored inaccessible to residents except for a a can of Lysol observed in a drawer in the common resident bathroom and a bottle of isopropyl alcohol observed accessible on a shelf in the common living area. Licensee removed both items immediately. Continued on 809-C... Continued from LIC809... Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Water temperatures in 2 of 2 resident bathrooms tested within the allowable range of 105 degrees F and 120 degrees F per regulation. LPA observed a locked shed in the backyard which is strictly used for equipment storage. Medications were observed to be centrally stored and locked. At approximately 11:15, LPA reviewed 5 staff and 5 resident files. LPA observed 5 of 5 staff missing the required initial medication training and were deficient 6 hours of dementia training and 4 hours of Hospice, Postural Supports, or Restricted Conditions Training. All staff have the required First Aid training and all but 1 have the required CPR training. Licensee to submit proof of CPR training for the remaining staff member to CCL. All 5 of 5 resident files has all the required paperwork, including current Individual Service Plans, however 4 of 5 were not signed by the resident or their responsible party. Licensee informed LPA that each has been reviewed with the respective resident and/or their responsible party. LPA advised Licensee to have these signed. LPA observed the centrally stored medication log to be maintained inaccurately with dates and directions not matching the prescription label on the bottle. LPA advised Licensee that all staff need to be trained on proper medication documentation, tracking and administration, to include not signing off on administrations prior to actually administering the dose. Licensee to submit updates of the following documents by 6/12/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E), Hospice Care Plan; control of property (lease); a copy of Liability Insurance; fire sketch; copy of fire clearance; . Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Licensee/Administrator. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.