Routine inspection·September 5, 2023

Licensing Program Analyst (LPA) Hansen, arrived unannounced to conduct an Annual Required 1 yr. Inspection and was welcomed by Monette Temple(caregiver), Administrator, Eric Moessing was contacted by staff and arrived during inspection. Facility has a fenced perimeter. There is a total of 14 residents, 9 of which have dementia diagnosis. There is 1 resident currently on Hospice. LPA initiated a tour of the facility at 8:40 am and made the following observations: Facility was a comfortable temperature and free from obstructions. Activity calendar observed and menus posted. Required postings were observed. Resident rooms were furnished per regulation. Water temperature in resident's bathroom faucets measured between 114.4 and 122 degrees F falling out of Title 22 acceptable range of 105 to 120 degrees F in 1 out of 4 resident’s bathroom faucets (see LIC 809-D). Extra hygiene products and linens were available. Bathrooms had required bathmats and grab bars. Toxins were in a unlocked cabinet in the kitchen (see LIC 809-D). Laundry room containing cleaning supplies were locked. Medications are centrally stored in the medication cabinet in the kitchen which was locked at the time of inspection; although LPA observed with caregiver unlocked closet next to front door containing multiple medications needing to be destroyed, accessible to residents in care 87465(i)(see pic)(see LIC809-D) Fire extinguisher was last inspected 10/18/2022. Facility has a hard wired smoke alarm system that is maintained by a vendor and inspected by the local fire department. Facility's last service was conducted Jan, 2023. Carbon Monoxide detector tested and found to be working. Last Disaster Drill was conducted on 8/23/2023. Auditory alarms were functional at the time of visit. LPA observed a few residents walking around the facility with a staff person to get exercise and facility was providing live piano with sing along. Continues on LIC 809C... File review was initiated at 10:30 am. Five staff files and five resident files were reviewed. 2 out of 5 staff do not have required First Aid and CPR certificates (see LIC 809-D). Three (staff S1,S2,S3)out of five staff do not have required TB test on file (see LIC 809-D). Medications and medication records were reviewed and 1 out of 5 residents medication records were not current (see LIC 809-D). Training records were reviewed. 1 out of 5 residents (R1) did not have a current needs and services plan (see LIC 809-D). LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any information. Disaster Drills are conducted quarterly with the last one being conducted on 8/23/2023. Administrator Certificates for Administrator Eric Moessing, 6017309740, expires on 8/16/2024. Appeal of Rights Given. 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. LPA Hansen is requesting Licensee to update the following documents and submit to CCL by 10/1/2023: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Administrator Certificate Copy of Certificate of Liability Insurance