Routine inspection·September 16, 2024

Licensing Program Analyst (LPA) Hansen, arrived unannounced to conduct an Annual Required Inspection of the facility and was welcomed by Janette (caregiver), Administrator, Eric Moessing was contacted by staff and arrived during inspection. There is a total of 15 residents, 8 of which have dementia diagnosis. There are 2 residents’ currently on Hospice. Facility has clearance for 15 non-ambulatory, 2 of which can be bedridden and a Hospice Waiver Approval for 6. LPA initiated a tour of the facility with staff at 10:20 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 111.2 degrees F and 113.5 degrees F within Title 22 acceptable range of 105 to 120 degrees F in 4 out of 4 resident’s bathroom faucets. Extra hygiene products and linens were available. Bathrooms had required bathmats and grab bars. Toxins are in locked cabinet in hallway closet, under kitchen sink & in locked laundry room. Medications are centrally stored in the medication cabinet in the kitchen which was locked at the time of inspection; although LPA observed two containers of medications for med pass on kitchen counter, accessible to residents in care 87465(i)(see pic)(see LIC809-D). Fire extinguisher was last inspected 10/6/2023. Facility has a hard-wired smoke alarm system that is maintained by a vendor. Facility's last service was conducted 7/2024. Carbon Monoxide detectors tested and found to be working. Auditory alarms were functional at the time of visit. File review was initiated at 11:15 am. Five staff files and five resident files along with 2 resident medication records were reviewed. All staff have required First Aid and CPR certificates. One staff (S1) out of five staff do not have required TB test on file (see LIC 809-D). One out of 5 staff (S2) does not have required Health Screening (see LIC-809-D). Continues on LIC 809C... Continued from LIC809 All staff requiring background checks have been cleared and associated to facility. All staff have required training. At approximately 12:15 PM resident records were reviewed finding all residents have current needs and service plans updated and all but 1 resident (R1) has updated Physicians Reports (see LIC 809-D). At approximately 1:20 PM Medications and medication records were reviewed and found to be up to date. 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 7/26/2024. Administrator Certificates for Administrator Eric Moessing, 6017309740, expired on 8/16/2024 although LPA observed, proof of pending certificate. 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 10/7/2024: LIC 308 Designated (if changes) LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate (when receive) Copy of Certificate of Liability Insurance