Routine inspection·February 26, 2024

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required visit of the facility. LPA was welcomed by staff Maria Botelho . Licensee Mary King was contacted by facility staff on the telephone and arrived later during this visit. There is a total of 11 residents, 5 dementia residents. There are 3 residents currently on Hospice. LPA toured the facility on 2/26/2024 at 8:45 AM with staff, Licensee jointed shortly after; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 2/05/2024 at the time of the visit. Facility smoke detectors were found to be operational on 2/26/2024. LPA observed 2 out of 2 Carbon monoxide detectors that were found to be operational during the visit. There are night lights in many of the common areas, resident’s bedrooms, and bathrooms of the facility. Hot water temperature measured between 113.1 degrees F and 115.8 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms while touring facility on 2/26/2024 at 9:15 AM. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day. LPA toured the kitchen area on 2/26/2024 at 9:15 AM with staff Maria and observed food stored in the refrigerator is labeled with dates. There are no special dietary needs for residents at the facility on 2/26/2024 at 9:20 AM. Food is available for residents any time of the day. At approximately 9:05 AM on 2/26/2024 LPA & Staff Maria observed unlocked spare medication cupboard containing 2 residents diarrhetic medications (see pic). Licensee immediately locked (see LIC809-D). Toxins are stored in a locked garage room. There was a supply of cleaners, hygiene products and paper products available for residents. Continue on LIC809-C in the facility at all times as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement , modifications and attachments, or notice of their availability from the facility.” A sample review of five resident & five staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 10:30 AM on 2/26/2024 and learned that 5 of 5 residents have current physicians reports & care plans on file at this time as required by Title 22 Regulation. Hospice care plans were up to date for each hospice resident. LPA conducted a sample review of staff records at 12:07 PM on 2/26/2024 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, 3 out of 5 Direct care staff have not received the additional training requirements as per Title 22 Regulations and H&S Code (see LIC809-D). LPA was presented with proof of CPR certification for staff although 3 out of 5 staff do not have First Aid certification (see LIC809-D) Medications were centrally stored in a locked medication cabinet in the facility medication cabinet. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 2/26/2024 at 1:30 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. LPA reviewed Licensing Information System (LIS) with Administrator who stated that is current and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have been conducted quarterly with the last one being conducted on 2/13/2024. Mary King Administrator Certificate # 6004998740 expires on 3/1/2025. Appeal Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided. Continue to LIC809-C LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 3/15/2024: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Control of Property Grant Deed Copy of Administrator Certificate Copy of Certificate of Liability Insurance