Routine inspection·February 8, 2024

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Licensees (Bot) and Edward Alicdan arrived later. Facility currently has 3 residents in care one of which is on hospice, which is allowable per the facility's Hospice Waiver. . At approximately 9:00am LPA and Licensee toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. LPA and Licensee observed the following food items to not be covered or labeled: sliced cake, 1/2 of a tomato, brown liquid in a cup, and red sauce in a bowl. Per Title 22 regulation 87555(b)(9) General Food Service Requirements - (b) The following food service requirements shall apply: (9)Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service ( deficiency cited, see 809D ). LPA and Licensee observed one bowl of cooked pasta on stove top in cooking pot not properly covered. Per Licensee, pasta left out overnight and during the day before, at room temperature. Per Title 22 regulation 87555(b)(23) General Food Service Requirements (b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures ( deficiency cited, see 809D ). LPA and Licensee observed kitchen drawer containing sharp knives not locked. Per Title 22 regulation 87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s) ( deficiency cited, 809D ). All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. LPA and Licensee observed rash bins in residents rooms are not covered. Per Licensee, trash bin in R2's room contained soiled brief for at least 2 days. Per Title 22 regulation 87303(f)(3) Maintenance and Operation (f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof ( deficiency cited, see 809D ). Continued on 809C... Continued from 809... Resident bathrooms had required bath mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 112.2 and 114 degrees F respectively, which is within the allowable range of 105 to 120 degrees F. LPA observed a 64 ounce jug of bleach accessible in the hallway shower and there was approximately 4 ounces remaining in the jug. Unlocked hallway closet had toxins accessible including acetone and disinfectants. Per Title 22 regulation 87705(f)(2) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.( deficiency cited, see 809 ). Fire extinguishers were last inspected 7/14/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Per LPA and Licensee observation and record review, facility has not conducted quarterly disaster drill since 2020, as documented in disaster drill paperwork. Licensee began to fill out fire drill paperwork dating it with a date in the future (2/10/2024) and signing the names of the attendees with date of attendance. LPA advised facility can not do the paperwork prior to conducting the actual drill as it may appear that the drill was not actually completed. Per Health and Safety Code HSC 1569.695(c) - Other Provisions (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenario... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill ( deficiency cited, see 809D ). Facility has a backup generator for use during a power outage. Upon LPA arrival to facility at approximately 8:45am, LPA observed medication cart in living room to be unlocked. All medication stored in cart was accessible to residents. Per Title 22 regulation 87465(h)(2) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for...the centrally stored medication ( deficiency cited, see 809D ). Continued on 809C... Continued from 809C... At approximately 9:15am LPA and Licensee observed unlocked drawer in kitchen to contain prescription Tramadol, unwrapped insulin syringe, and pre-poured medication in dishes. Per Title 22 regulation 87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers ( deficiency cited, see 809D ). Syringe for insulin found accessible in unlocked kitchen drawer. Syringe was unwrapped from packaging and possibly was used. Per Title 22 regulation 87303(f)(2) Maintenance and Operation (f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens ( deficiency cited, see 809D ). At approximately 10:00am LPA observed resident's bathroom shower (R3) in room #1 to have the drywall/sheet rock missing from around shower spigot and pipe(s) exposed. Per Title 22 regulation 87307(d)(2) Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment ( deficiency cited, see 809D ). At approximately 1:00pm LPA conducted a review of three resident records. Facility has one resident (R1) that is bedridden but does not have bedridden fire clearance and could not produce proof of notification to fire department. Per Title 22 regulation 87606 Care of Bedridden Residents (b) A facility shall notify the local fire jurisdiction within 48 hours of accepting or retaining any bedridden person, as specified in Health and Safety Code Section 1569.72(f).( deficiency cited, see 809D ). Resident (R1) did not have a current LIC602 Physician's Report, last report dated 2022. Per Title 22 regualtion 87705(c) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually... ( deficiency cited, see 809 ). R1 did not have a current Appraisal Needs and Services plan (Care plan) on file. Per Title 22 regulation 87705(c) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals ( deficiency cited, see 809D ). Continued on 809C... Continued from 809C... At approximately 2:00pm LPA conducted a review of two staff records. Both staff (S1 and S2) were missing required training. Per Health and Safety Code HSC 1569.695(b)(2)87458(b)(1) (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training ( deficiency cited, see 809D ). Staff (S1) did not have Health Screen on file. Per Title 22 regulation 87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:(11) A health screening as specified in Section 87411, Personnel Requirements - General ( deficiency cited, see 809D ). Luningning Alicdan, Administrator Certificate 6010428740 expired October 2023; however, certificate is currently in Renewal-Pending status. All fees are current as of this time. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Evidence of Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.