Routine inspection·January 21, 2025

Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a required- 1 year inspection, on 1/21/25 at approximately 12:30pm, and met with Administrator Teresita Shevick. LPA observed a caregiver on duty during the inspection, Cindy Magnuson. Facility is fire cleared for six (6) non-ambulatory residents, of which one (1) may be bedridden. Facility has an approved dementia plan of operation. Hospice waiver approval is for three (3) residents. Facility has a required infection control plan. Facility has a required emergency disaster plan. Per file review. last emergency drills were held on 12/12/24, Earthquake drill, and on LPA reviewed five (5) resident files; All records were complete. LPA reviewed four (4) staff files, including training. All staff had required criminal record clearance. All staff had required first aid certification. S4, caregiver had both first aid and CPR certification. LPA toured the facility with the Administrator. Hot water was checked at 117.1 degrees Fahrenheit, which is within regulation. The facility was observed to be at a comfortable temperature. The food supply was sufficient in perishable and non-perishable items. All exits had working auditory alarms, all exits were clear and unobstructed. There was a sufficient supply of paper products, cleaners/disinfectants, personal protective equipment (PPE), and hygiene products. There was sufficient lighting in all common areas, resident rooms, hallways, and bathrooms. Sufficient furnishings throughout the facility for resident use. Fire extinguisher was serviced and tagged as required. LPA discussed fire clearance and regulation requirements with the Administrator regarding the backyard walkways and fire exit path are to remain clear and unobstructed at all times; Administrator stated to the LPA their understanding of the above information discussed. Continued on LIC809C... LPA is requesting the following documents be updated and submitted by 2/21/25: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required) Infection Control Plan (ensure to review and update as needed/required) LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Copy of Current Liability Insurance Resident Roster Copy of current Administrator Certificate . The following deficiencies were observed by the LPA during the inspection: Per LPA's file review, there have been two (2) emergency disaster drills held, 12/24 & 10/24, both were earthquake drills; In review of facility emergency disaster drills the requirement has not been met. This deficiency will be cited, HSC 1569.695 (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. 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, see LIC809D. Per LPA file reviews, staff, S1, S2, & S3, all lack current CPR certification.This deficiency will be cited, HSC 1569.618(c)(3)-Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR, see LIC809D. Deficiencies 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 with Administrator/Licensee Teresita Shevick. Appeal Rights provided to the Administrator.