Routine inspection·July 18, 2024

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver (S1). Caregiver (S2) arrived later. Administrator Fikre Gurja was contacted by phone. Admin out of the country. Admin gave caregiver S2 permission to sign. Facility contact information was reviewed. Facility staff roster was reviewed. S1 not associated to the facility. S1 has been working at facility since October of 2023. In addition to not being associated to the facility, S1 also does not have fingerprint clearance. Per Guardian background check system, S1 has an incomplete application and was notified of such on 9/17/2023 ( deficiency cited, see 809D and *civil penalty assessed* in the amount of $500 ). LPA advised S2 and S1 that S1 must leave the facility and not return to work or provide any care to residents until fingerprint clearance is obtained and they are associated to the facility. At approximately 9:30 am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. LPA and caregiver observed package of Keebler Club crackers opened but not covered or labeled with date opened. Canned goods found to be stamped with expired Best If Used By (BIUB) dates: one can of Bruce's Yam 12/22/2023, one bottle of Hidden Valley Ranch dressing 5/30/2024, two [2] cans of S&W garbanzo beans 11/18/2023, one can of Swanson's chicken broth 11/11/2023. Frozen beef steak dated 10/27/2023 ( deficiency cited, see 809D ). Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives was open but has locking function. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bars. However, mats in all 3 resident bathrooms were found to have black and brown substance on the underside of the mat, two of which had the substance almost covering the entire surface, one of which had varied spotting of the black substance ( deficiency cited, see 809D ). Continued on 809C... Continued from 809... Water temperature in sink accessible to residents in care measured at 116.9, 119.4, and 119.4 degrees F which is within the allowable range of 105 to 120 degrees F. LPA advised caregiver that the 119.4 is very close to the maximum allowable temperature of 120 degrees F, so licensee may consider turning down the water heater slightly as a preventative measure. Fire extinguishers were last inspected 6/19/2024. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted 6/25/2024. Facility has a backup generator for use during a power outage At approximately 11:30am LPA conducted review of 5 staff records. All required documentation present. At approximately 1:30pm LPA conducted a review of 3 resident records. R1 has DX of dementia but most recent medical assessment dated 11/11/2022 and most recent appraisal dated 8/20/2022 ( deficiency cited, see 809D ) At approximately 2:00pm LPA and caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. During spot check of medication, LPA and S2 observed: R2 to have prescription for Lisnopril rx#161458369 to be missing fill date on Centrally Stored Medication log (CSML). R3 had bubble pack of Tramodol with no start date but 3 pills missing. Per caregiver, bubble pack arrived with resident upon move in, but has not taken any since admission, but no notes on CSML indicating as such. LPA advised that some note must be made to account for missing pills. R2 had prescription for Quetiapine in the amount of 300 mg daily (100mg in the morning and 200mg at night), LPA and caregiver observed a count of 50 remaining in the bottle with an original fill quantity of 90, start date was 6/28/2024 and fill date was 5/23/2024. Count was off, indicating missed doses. Caregiver explained that on 5/17/2024 and 6/24/2024 the prescribed dose was changed. LPA advised 5/17/24 is before fill date of 5/23/24, so prescription should have been changed before filling in order to ensure accurate fill, accurate dosing, and accurate entry on CSML ( deficiency cited, see 809D ). Continued on 809C(2)... Continued from 809C... Fikre Gurja Administrator certificate #7029598740 exp 1/7/2025 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 Current Lease Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. *Civil Penalty assessed* Appeal rights given and discussed with caregiver S2. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with caregiver S2 and a copy of this report was given .