Routine inspection·November 16, 2023

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required - 1 yr. visit of the facility. LPA was welcomed by staff Laura Lopez Monroy. Angelica Martinez - Licensee was contacted by staff and arrived during the visit. There were two caregivers providing care and supervision for 3 residents. Three residents were at day program. There is no residents currently with a diagnostic of dementia, as well no residents on Hospice or using oxygen. LPA initiated a tour of the facility at 9:00 AM on 11/16/2023 and made the following observations: Facility was found to be clean and at a comfortable temperature with all passageways and exits free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathrooms measured at 118.5 degrees F and 119.1 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 11/16/2023. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinet in garage containing cleaning supplies and toxins was unlocked along with cabinet underneath kitchen sink containing cleaning supplies, Regulation 87309(a)(see LIC809-D). Bathroom contained cloth towels and no paper towels for clients use, Regulation 87307(3)(c)(TV see LIC9102). Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored in kitchen cabinet although unlocked, Regulation 87465(h)(2) (see LIC809-D). Fire extinguisher was last inspected 9/15/2023. Smoke detectors and Carbon Monoxide detectors located throughout facility were tested and operational. All six exit doors have auditory alerts that were functional at time of visit. Continued on LIC809C Continued from LIC809 A review of 6 resident & 6 staff records as well as two resident’s medications was conducted during this visit. LPA reviewed resident’s files at 10:45 AM on 11/16/2023 and learned that 6 of 6 residents have an updated re-appraisals/needs & care plans, IPP's and updated physician’s assessments (LIC 602A) on file. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 11/16/2023 at 1:30 PM; although facility is pre-pouring medications (see pics) in kitchen and outside office, Regulation 87465(h)(5) (see LIC 809D) Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be incomplete and inaccurate per regulations (see TV LIC9102) LPA reviewed a sample of staff records and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff files have proof of annual training requirements for 2023 on file. LPA was presented with proof of CPR for required staff although none of the six staff had required 1 st Aid certification in files that were reviewed, Regulation 87411(c )(1) (see LIC 809-D). Administrator Certificate for Angelica Martinez 6001706740 expires 4/10/2025. LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Administrator informed Disaster Drills are conducted every six months although regulations is quarterly with the last disaster drill being conducted on 1/18/2022, over a year ago out of Title 22 regulations HSC 1569.696(c). 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. Continue on LIC809-C LPA Hansen is requesting facility to submit the following documents to CCL by 12/05/2023: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Current Administrators Certificate Copy of Control of Property Deed Copy of Certificate of Liability Insurance