Routine inspection (multi-day)·January 4, 2024

Licensing Program Analyst(LPA) Alviso conducted a continued annual inspection, at approximately 1:45pm on 1/4/2024, and met with, Administrator Monicah Gacegu. LPA observed two caregivers on duty, Consulata and Pauline. There are currently five residents in care. The facility is fire cleared for eight (8) non-ambulatory. Hospice waiver is approved for three (3). Facility has a dementia plan of operation. The facility has a required infection control plan. Facility has an emergency disaster plan as required. LPA reviewed five (5) resident files. All files were complete. LPA reviewed three (3) staff files, including training. All staff have criminal record clearance as required. All staff have First Aid and CPR certification as required. Staff have required training. The LPA toured the facility with the caregiver Consulata. The bathrooms were clean, all had grab bars, and mats/non-slip flooring for resident use as needed. There was sufficient lighting in the hallways, resident rooms, bathrooms, and in all common areas. Hot water was checked at 117.4 degrees Fahrenheit. Facility has sufficient food supply, hygiene products, paper products, and cleaners. Sufficient supply of PPE. Sufficient emergency supply to meet 72 hour shelter in place requirements. Deficiencies observed that will be cited today, see LIC809Ds. R1's room smelled strongly of urine, and the urine odor can be smelled in the facility's hallway, where R1's room is located. Cited-87625(b)(3) Managed Incontinence) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This is a 2nd citation within 12 months, a civil penalty assessed in the amount of $250-see 421FC Continued on LIC809C... LPA's observations of medication bottle on resident(R1's) night stand. The medication should be centrally stored as required by regulations. Cited-87465(h)(2) The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This is a 2nd citation within 12 months, a civil penalty assessed in the amount of $250-see 421FC LPA is requesting the following documents be updated and submitted by 2/4/24: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan- review and if no changes, submit a copy of last page w/signature & Date. If changes, submit a copy of the plan. Infection Control Plan-review and if no changes, submit a statement w/signature & Date. If changes, submit a copy of the plan. Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond if handling cash.. Copy of Current Liability Insurance Copy of current Administrator Certificate 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 Monicah Gacegu. Appeal rights were provided.