Routine inspection·December 10, 2024

Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 12/10/24 at approximately 10:00am, and met with Licensee/Administrator Angelica Martinez. Fire clearance is approved for six (6) non-ambulatory, of which one (1) may be bedridden. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Facility has an infection control plan as required. Facility has an emergency disaster plan as required. LPA toured the facility with the Administrator. Hot water was checked at 116. degrees Fahrenheit, which is within regulation. The food supply was sufficient in perishable and non-perishable items. The facility had a sufficient supply of linens, furnishings, paper products, hygiene items, cleaners/disinfectants, and personal protective equipment (PPE) for use by the facility. The exits were free and clear from obstruction. All medications were locked and inaccessible to residents in care. All cleaners/disinfectants were locked and inaccessible to residents in care. Facility has two (2) fire extinguishers that were serviced and tagged as required. The facility had all required smoke alarms, all working appropriately. Facility carbon monoxide detector was working appropriately. All exits had auditory alarms. There are currently five (5) residents in care; Four (4) of the residents were at day program during the inspection. LPA reviewed five resident files, including medication records. LPA reviewed four staff files, including training. All staff have criminal record clearance as required. All staff have first aid and cpr certification as required. Continued on LIC809C... LPA is requesting the following documents be updated and submitted by 1/10/25: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan (ensure to review, update as needed/required- submit copy) Infection Control Plan- (ensure to review, update as needed/required- submit copy) Copy of 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 during the inspection: Per review of records, there was no documentation showing proof of having conducted required emergency disaster quarterly drills; Administrator was not able to show proof of quarterly drills having been conducted. 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, taking into account different emergency scenarios. 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 record reviews, S1, S2, and S4 lacked CPR certification, and S3 lacked first aid and CPR certifications. Administrator was not able to show proof of staff having the training specified above for each staff. This deficiency will be cited, HSC 1569.618(c)(3) Other Provisions Section – Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and staff have 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 Licensee/Administrator Angelica Martinez. Appeal rights given to the Administrator.