Post-licensing visit·June 23, 2023

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a post-licensing and Non-Compliance inspection. LPA met with Lead Staff, Diandra Chadwick. Licensee, Alex Varshavsky was not able to come to the facility, but was available by phone and gave authorization for lead staff to sign the report. The facility has residents receiving hospice services and residents with a diagnose of Dementia. LPA observed residents were participating in an exercise activity. Upon arrival, LPA confirmed with Lead staff that they are following current Covid19 and masks guidance. Facility is a one story building and have an approved fire clearance dated November 16, 2022 that allows for 28 non-ambulatory residents and 6 bedridden resident. Fire Extinguishers were last serviced January 2023. Facility has a centralized fire alarm system that is maintained by a vendor and inspected by the local fire department. Facility's last maintenance was conducted 2/7/23. Facility has a locked perimeter. Smoke detectors, sprinklers, carbon monoxide detectors were present throughout the facility. LPA/lead staff pulled alert codes and staff responded in a timely manner. Fire panel was last inspected 07/2022. Last disaster drill was conducted on April 10, 2023. Exits and walkways were free from obstructions. Exit alarms were working properly. LPA observed required postings. Facility had sufficient perishable and non-perishable food. Facility front porch has an area for visiting and activities. Facility has first aid kit which was found to be appropriate during the Post-Licensing inspection. Emergency food and water supplies are stored in the kitchen pantry. All resident’s bedrooms have lighting & appropriate furnishings, and resident’s beds were outfitted with mattress pads as required by Title 22 Regulations. Continues on LIC809C... Continued from LIC809... Bathrooms had necessary grab bars and non-slip mats. Medications were centrally stored and secured. Hoyer lift machine is working properly. LPA observed activity calendar and weekly dated menu. LPA reviewed 10 residents and 10 staff files. Residents have current medical assessments and care plans. Staff records indicated that CPR/1st aid and received required annual training hours. Administrator certificate for Alex Varshavsky # 6052513740 expires on 7/15/2023. At approximate 9:00am LPA/Lead staff toured building, grounds and found missing face cover plate in room# 7, bathroom in room #6 has an out of order sign, there are two drawers missing in shared bathroom for room# 4 and 5. At approximate 9:30am LPA/Lead staff observed hot water temperature measured at 123.8, 118.6, 121.6, 122.4, 108.1, and 127.9 degrees in resident's bathrooms which are not within regulation. At approximate 10:00am LPA/Lead staff observed that admission agreements were not updated after Change of Ownership. Per Lead Staff, they will create an addendum including the use of surveillance cameras in common areas and will have residents and their responsible parties sign them. LPA followed up on items to ensure compliance with Non-Compliance Conference dated 7/28/21: CCR 87211 Reporting Requirements - Facility did not ensure that CCL was notified about incidents after falls occurred on 2019 and 2020 including resident with Prohibited Condition (Stage III) wound. LPA reviewed incident report logs that confirmed that facility has been reporting incidents to CCL within regulations. CCR 87465(g) - Incidental Medical and Dental Care - Facility failed to seek timely medical attention. LPA reviewed incident report logs received within 7 days as indicated per regulation. Continues on LIC809C... Continued from LIC809C... HSC 1569.269 (a)(5) Enumerated Rights - Facility did not ensure that resident was accorded safe, healthful and comfortable accommodations which resulted in resident’s death as a result of a serious fall at the facility. LPA/Lead Staff observed residents who appeared to be safe, healthful and comfort. CCR 87466 Observation of the Resident - Facility did not observe change of condition in resident after fall . LPA reviewed ten residents (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10) records and residents have been assessed for change of condition within the last 12 months per regulation. CCR 87705 (c)(4) Facility didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. LPA/Lead staff reviewed staff schedule for the month of June 2023 and facility has 6 direct care staff, 1 housekeeper, 1 kitchen for the morning shift; 5 direct care staff for the afternoon shift, 1 kitchen staff and 2 direct care staff for night shift to help with resident's needs. LPA reviewed staff training records and most of staff (S1 through S11) has received an average of 52 hours annual of training including care of persons with Dementia. CCR 87506 Resident Records - Facility provided LPA with resident's care notes for review . Facility provided a care binder including memorandums from Administrator to staff, shower/teeth schedules, resident's weights, meals, incontinence care records to document daily resident's care notes. LPA/Lead staff observed daily care notes with initials documented for each resident. Administrator will provide copies of the following by 7/7/2023: LIC 308 Designated of facility responsibility, LIC 500 Personnel Summary, LIC 610 Emergency Disaster Plan (if there are any changes), Copy of Administrator Certificate, Copy of Certificate of Liability Insurance 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 Lead Staff and appeal of rights provided.