Routine inspection·August 3, 2023

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. visit of the facility. LPA was welcomed by staff Joyce Torres. LPA met with Teddy Rico, Licensee. There is a total of 6 residents and 3 with a diagnostic of dementia. There is one resident currently on Hospice. LPA toured the facility on 8/3/2023 at 10:50 AM with licensee, Teddy Rico; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices which were working properly at the time of the visit. Fire Extinguisher was found to be last charged on 1/23/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured between 114.9 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 8/3/2023. 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 food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Sharps were stored in locked drawer in kitchen although some knives were also observed by LPA and licensee on 8/3/2023 at 11:01am in unlocked kitchen drawer (see LIC809-D). Toxins stored in a cabinet in the garage has broken lock (see LIC809-D) and exit door from kitchen to garage was turned off at the time of the visit on 8/3/2023 at 11:05 am (see LIC809-D). There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 8/3/2023 at 11:10 AM. Continue on LIC 809-C A review of five resident & four staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 11:45 AM on 8/3/2023 and learned that 3 of 5 residents have an updated re-appraisals/needs (R1 & R2 re-appraisals have not been updated see LIC 809-D) & care plans and physician’s assessments (LIC 602A). Medications were centrally stored in a locked cabinet, pre-poured (see LIC9102 TV) in the facility kitchen area; although during tour on 8/3/2023 at 10:55 am with licensee, medications to be disposed were found in kitchen cabinet not containing a lock (see LIC 809-D). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 8/3/2023 at 10:00 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. LPA reviewed a sample of staff records at 8:45 AM on 8/3/2023 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements for 2022 are on file. LPA was presented with proof of CPR & 1 st Aid although 1 of 4 staff did not have current 1 st Aid (see LIC 809-D) certification for staff that files were reviewed. Jordan Rico Administrator Certificate # 6039905740 expires on 5/19/2024. LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information other than the mobile phone number. 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 often with the last one being conducted on 5/19/2023. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.. Continue on LIC 809-C LPA Hansen is requesting Licensee to submit update documents to CCL by 9/3/2023: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of updated Lease Agreement Copy of Administrator Certificate Copy of Certificate of Liability Insurance