Routine inspection·February 20, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver, LVN. Administrator not available to come to the facility but was available periodically via telephone. At approximately 9:00am LPA and caregiver toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. Black substance present in grout and spotted black film around sink in grout, LPA observed the same issue during last annual inspection dated 3/22/24 ( deficiency cited, see 809D ). Thick-it food and beverage thickener found in the pantry with prescription label torn off and date of expiration covering where label was. LPA advised this is a prescription item and cannot be shared between residents that do not have a prescription. LPA found zinc oxide and vitamin C in hall closet, unlocked and accessible to residents. LPA advised all vitamins and supplements must be stored inaccessible to residents. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms in good repair; however, there was a pervasive odor of urine incontinence present in the facility, coming from rooms #1 and #3 ( deficiency cited, see 809D ), odor was noticeable immediately upon entering the facility. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Bathroom in room #4 has a shower that has brown substance present in shower and chunks of a white substance concentrated over the drain. LPA advised caregiver, LVN that even if the shower is not presently used, it should remain clean. Water temperature in sink accessible to residents in care measured at 113.6 and 107.1 and degrees F which is within the allowable range of 105 to 120 degrees F. Continued on 809C... Continued from 809... Fire extinguishers were last inspected today. Smoke/Carbon Monoxide detectors located throughout the are operational. Facility’s last quarterly disaster drills were conducted in 2024. LPA advised that drills must be performed quarterly. Facility has a backup generator for use during a power outage. LPA observed a discarded hospital bed partially obstructing the emergency fire exit path on the side of the house. LPA and caregiver discussed that fire exit cannot be obstructed ( deficiency cited, see 809D ). At approximately 10:30am LPA conducted a review of 5 staff records. LPA reviewed training documents. Training log document shows staff training completed by instructors Administrator Gloria Taduran, RN and caregiver, LVN. Training completion dates listed as: S1 hired 11/15/2023: 12/1/23: 5 hours training from CCO and 15 hours with a date 11/15, but no year listed S2 hired 11/20/2023: 6 hrs 12/6/24, 5 hours on 12/12/24, 4 hours on 12/28/24, and 7 hours on 1/8/25 S3 hired 02/07/2024: 21 hours training on 2/7, but no year listed S4 hired 11/29/2022: 15 hours on 5/1/24 S5 hired 04/06/2023: 15 hours on 4/4/24 and 7 hours on 4/7/24 S6 hired 01/20/2024: no training documented/on file S7 hired 12/20/2024: no training documented/on file LPA advised that if a staff member is within their first year of employment they must have completed 40 hours of training; 20 of which must be completed before working independently with residents; additionally, those staff that have completed their initial year of employment must complete a total of 20 hours annually ( deficiency cited, see 809D ). LPA discussed with Admin and caregiver, LVN accuracy of date on which the training occurred. Admin and caregiver, LVN confirmed. LPA discussed with Admin and that there are only 24 hours in a day and therefore it appears that the training records have been fabricated. Admin and caregiver, LVN agreed to cease using handwritten training log and personal training materials. Admin and caregiver, LVN agree to Continued on 809C(2)... Continued from 809C... instead use an approved vendor from which they will print the training completion certificates for each respective staff. The approved vendor they committed to using is Senior Community Learning . LPA discussed with Admin and caregiver, LVN that all personnel, whether on-call or full time must have their personnel file present at the facility. Full time regular staff (S7) and on-call staff (S6) did not have Health Screen, Training, TB, or any paperwork at all on file or present at facility ( deficiency cited, see 809D ). Staff (S2) has expired First Aid expired as of 1/10/2025 and staff (S4) did not have any First Aid on file ( deficiency cited, see 809D ). Staff (S6) was not associated to the facility, furthermore, they did not have any paperwork present at the facility ( deficiency cited, see 809D ). At approximately 11:30am LPA conducted review of six [6] resident records. Four [4] of five [5] residents required to have half rails on order have half rail order present on file. LPA advised be sure all residents that have half rails present also have the half rail doctor orders on file. Resident (R1) has an appraisal on file but not current (11/2023) and residents (R2 and R3) did not have an appraisal on file at all ( deficiency cited, see 809D) At approximately 2:00pm LPA and caregiver, LVN conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Facility uses a MAR. LPA advised caregiver, LVN that a MAR is not required per regulation; however, if facility uses a MAR, then CCL can audit it. A few entries for residents missing on MAR but per caregiver, medication was administered. LPA advised that a PRN MAR is required per regulation. PRN MAR present. Prescribing physician entry missing for R3 on all Centrally Stored Medication Log (CSML) entries. LPA advised that recording the date started is not required per regulation but is a best practice. Caregiver, LVN agrees to start recording the date started on CSML. LPA discussed with caregiver, LVN crushing residents' medications. Caregiver, LVN advised LPA that they crush medications for two [2] residents to mitigate choking but could not produce a doctor's order or show where the medication is prescribed as needing to be crushed to be administered. Caregiver, LVN advised LPA they will get the doctor's order and maintain it in each respective resident's file. Continued on 809C(3)... Continued from 809C(2)... Gloria Taduran Administrator Certificate 7028332740, which is currently in Pending Renewal status. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with caregiver, LVN. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with caregiver, LVN and a copy of this report was given .