Routine inspection·March 27, 2024

Licensing Program Analyst’s(LPA’s) Shannan Hansen & Julie Florio arrived unannounced to conduct an Annual Required inspection and met with Licensee, Laarni Lockerbie & Administrator, Aira Monte. There is a total of 6 residents, 1 under hospice care & 2 with diagnosis of dementia. LPA’s initiated a tour of the facility at approximately 8:45 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. While touring kitchen at approximately 8:50am LPA’s observed cleaning supplies in unlocked cabinet under sink accessible to residents in care (see pic & LIC809-D). Resident’s rooms were furnished per regulation. Water temperature in bathrooms measured at 111.3, 111.7, and 112.1 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Bathrooms used by resident to shower were equipped with necessary grab bars and non-slip floors/mats. While touring bathrooms LPA’s observed with staff (S2) supplements in unlocked drawer and immediately removed by staff(see pics & LIC809-D). Extra hygiene products and linens were available. Cabinet containing cleaning supplies in garage was locked; although upon entering, door to garage was unlocked and alarm was not turned on, LPA’s found razor cutting knife accessible to residents in care and removed by staff (see pics & LIC809-D). There was enough lighting in all common areas, resident rooms, and hallways. Fire extinguisher was last inspected 3/11/2024. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. At approximately 9:15 AM, LPA’s reviewed 6 of 6 resident records and found 6 of 6 residents have current physician’s reports and care plans. 6 of 6 resident records contained current and signed admission agreements and physician’s orders on file. Continue on LIC 809-C At approximately 10:20 AM, LPA’s review 5 of 5 staff records. 5 of 5 records contained documentation of completed training as required. Evidence of current first aid and CPR training were observed. 4 out of 5 staff did not have required Health Screening records (see LIC 809-D). Medications were centrally stored in locked cabinet in the facility living room although second cabinet containing overflow of medications was not locked and accessible to residents in care (see pic & LIC809-D). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 3/27/2024 at 11:30 AM. At approximately 12:10 PM, LPA reviewed the facility emergency disaster plan with staff. Facility does not have a generator to supply power during an outage. Administrator informed they are currently deciding how to handle emergency outages with residents on oxygen and other. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts disaster drills quarterly and documented last disaster drill on 2/23/2024. Administrator Certification for Aira Melanie U Monte 6056005740 expires 08/29/2024. LPA reviewed Licensing Information System (LIS) with Licensee who stated that is correct and updated at this time; no need to change any of the information. Appeal Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided. LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 4/10/2024: LIC 308 Designation of Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Register of Facility Client’s/Resident’s Proof of Liability Insurance