Routine inspection·October 17, 2023

Licensing Program Analyst (LPA) Cuadra arrived unnanounced to conduct a Required Annual Inspection and met with Alberto Aparicio (caregiver). Pamela Johnson (Licensee) was not able to come to the facility, but was available by phone and gave authorization for staff to sign the report. There is currently no residents in hospice and residents with a diagnosis of dementia. Required postings were observed. All fees are current as of this time. LPA/staff toured the facility grounds inside and outside and made the following observations: Facility was a comfortable temperature with thermostat reading at 78 degrees F. Passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Medications were centrally stored and locked. Fire extinguisher was last inspected May 2023. Smoke and Carbon Monoxide detectors were tested during inspection and operational. Exit doors have auditory alert system that were functional at time of visit. Last Disaster Drill was conducted on June 16, 2023. Licensee agreed to conduct a disaster drill every quarter as stated per regulation. A technical advisory will be issued. Cleaning supplies were not accessible to residents in care. Knives are located in a locked closet in the kitchen. Facility has at least two days of perishable & one week of non-perishable foods. At approximate 9:00am LPA/staff observed water temperature in resident's bathrooms measured at 121.1, 121.5 & 121.6 which are not within allowable range of 105 to 120 degrees F in faucets used by residents. Continue on LIC809C... Continued from LIC809... At approximate 9:30am LPA/staff observed main fridge located in the facility kitchen was locked. Per staff, they do lock it due to resident's behavior to wake up at night and opens the fridge. LPA discussed with Licensee that a waiver request needs to be submitted to the Department for review and approval if they wish to have a locked fridge, outlining why the refrigerator needs to be locked and how adequate and readily available snacks and beverages will be provided to residents. Licensee agreed a waiver request and its supporting documents would need to be submitted to the Department. LPA observed staff removed the lock from the main fridge during visit. Resident's daily care notes are updated. File review was initiated at 10:30 am. Five resident files were reviewed. All residents files have current medical assessments and needs appraisals/care services plans updated. Staff on duty have required First aid and CPR certificate updated. However, Licensee informed LPA that all staff records were locked in the facility office. LPA will return to review staff files to ensure that staff have their files current. Administrator Certificate for Pamela Johnson 6018738740 expires 7/27/24. Medications and medication records were reviewed. Licensee agreed to submit updates of the following documents by 10/31/2023: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), control of property and liability insurance. 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 given. Exit interview conducted with staff, Licensee was aware of deficiencies via phone and copy of report was given.