Routine inspection·June 19, 2024

At approximately 8:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Andrea Dela Chica. Licensee/Administrator, Bot Alicdan, arrived during visit at approximately 9:00AM. Facility serves older adults and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 13 residents of which 11 residents can be non-ambulatory, and 2 residents can be bedridden. Facility has an approved hospice waiver for 3 individuals. Facility has approval to have a locked perimeter. Upon arrival, LPA was informed that there were 9 Residents in care and 2 staff members on-site. At approximately 8:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were not associated to the facility per regulation. LPA confirmed on the Guardian website that the two staff members were background cleared but not were associated to the facility as required (deficiency cited, see LIC809D and LIC421BG, regulation 87553(e)). At approximately 9:25AM, LPA conducted a walk-though of the facility with Licensee. Per Facility sketch, facility is a one story building with 11 bedrooms, 11 bathrooms, and common spaces. LPA observed the following: facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. 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. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for 7 of 13 facility sinks were found to be out of compliance with Title 22 Regulations of 105 to 120 degrees Fahrenheit, measuring between 120.5F to 126.8F (deficiency cited, see LIC809D, regulation 87303(e)(2)). During walkthrough, LPA observed the following toxins, hazards, and medications to be accessible: unlocked knife drawer in the kitchen, Disinfectant cleaner in the bathroom, bed bug repellent in a cabinet located in the dining room. LPA also observed blood sugar monitors and sharps located in the facility's dining room drawer, and 3 bottles of cough syrup, 1 bottle of Pepto Bismol and 1 bottle of Tums in a resident's room. Review of resident's LIC602 stated that resident has a dementia diagnosis and is unable to manage their own medications (deficiencies cited, see LIC809D, regulation 87705(f)(2)). Licensee immediately collected all toxins and ensured that they were locked and inaccessible. Licensee also removed medications from resident's room. Continued on LIC809C Continued from LIC809 LPA observed that a window in a resident's room needed replacing. Per LPA observation, the window was being propped up by a fake piece of fruit. Further observation showed that the window was loose and could not withstand its weight when opened (see technical violation, LIC9102, regulation 87303(a)). LPA observed that some resident rooms had garbage cans with lids, while other resident rooms did not have garbage cans with lids (see technical violation, LIC9102, regulation 87303(f)(3)). LPA also observed prepoured PM medications in a locked cabinet. Per conversation with Licensee and Staff Member, the PM medications were poured this morning. Review of visit conducted on 06/01/2023 indicated that the facility was issued a technical advisory and therefore was aware that pre-pouring medication was against regulation (deficiency cited, see LIC809D, regulation 87465(h)(5)). Facility's fire extinguishers were last inspected May 2024. Smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted May 2024. At approximately 11:30AM, LPA reviewed staff files, resident files, and resident medications . Review of staff files showed that Staff Member 3 (S3) was missing their Health Screening (LIC503) report and proof of negative TB test. 3 of 4 staff members did not have annual 2023 training completed (deficiencies cited, see LIC809D, Regulation 87411(f), and Health and Safety Code, 1569.625(b)(2)). Per discussion with Licensee, all staff have been signed up for online training. 3 of 4 staff files had current First Aid and CPR certification. Per discussion with Staff Member 1 (S1), their certification card is at home but they always work with Staff Member 2 (S2) at the facility. Review of S2's file indicated that they had current first aid/cpr certification (see technical violation, LIC9102, 1569.618(c)(3)). Review of resident files showed that 3 of 9 resident files were missing their reappraisal assessments. Of the 9 residents, 2 residents with a diagnosis of dementia were missing updated annual Physician Reports. 9 of 9 resident files were missing their Needs and Services Plan. 1 of 9 files was missing their Pre-Appraisal Assessment (deficiencies cited, see LIC809D, regulation 87705(c)(5), regulation 87467(a)(2), and regulation 87467(a)). Licensee understands that Pre-Appraisal assessments should be conducted prior to residents moving into the facility. Licensee also understands that assessments and appraisals should be conducted annually for residents with a dementia diagnosis. LPA reviewed 4 of 9 resident medications. During review, LPA observed that some medications were not centrally stored as required. LPA observed that some medications were either not logged or had incorrect dates logged (deficiency cited, see LIC809D, regulation 87465(h)(4)). Administrator Certificate for Luningning (Bot) Alicdan (6010428470) expired 10/18/2023. Review of Guardian's website showed that Licensee/Administrator's name is not on the pending list or active list. Per Guardian website, renewal applications are being reviewed for the week of 11/06/2023. Licensee informed LPA that they submitted payment for their renewal in 2023. Continued on LIC809C Continued from LIC809C LPA requested the following documentation to update the facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 07/19/2024. 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. **An Immediate Civil Penalty in the total amount of $200 is being assessed for a lack of staff association as required for S1 and S2 (See LIC421BG).** Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), LIC421BG (Civil Penalties for Caregiver Background Check) Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.