Routine inspection·November 14, 2024

Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 11/14/24 at approximately 1:35pm, and was greeted by caregiver Isabel. There are currently six (6) residents in care; Currently there are two (2) residents on hospice care. Administrator arrived to meet with the LPA. There is an approved hospice waiver for three (3) residents. Facility has an infection control plan as required. Facility has an emergency disaster plan as required. Facility has an approved dementia plan of operation. Facility has a fire clearance approval for a total of six (6) non-ambulatory residents. The facility's last fire drill was held in October, and the evacuation drill is scheduled for 2024. Facility does have a generator for emergencies if needed. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. LPA reviewed five (5) resident files; All resident files were found to be complete. Medications were observed, and reviewed, including PRN medication records. LPA reviewed five (5) staff files. LPA reviewed staff training. All five(5) staff have criminal record clearance, and are associated as required. All staff had required training. All staff had current First Aid and CPR Certification. LPA observed sufficient supply of food, perishable and non-perishable, for resident meals/snacks. Facility had sufficient furnishings for residents in care. The facility has sufficient lighting in all rooms, bathrooms, and common areas, including night lights. There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed.Facility has a sufficient supply of personal protective equipment (PPE). All medications were stored/locked and inaccessible to residents in care. All cleaners/disinfectants were locked up inside the facility, and inaccessible to residents in care. Continued on LIC809C... All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed; Two resident rooms have access to a bathroom, with shower stall, that is right outside of their rooms. Three resident rooms have a private half bath, and one resident room has a full bathroom. There is a full bathroom in the long hallway for resident use as needed. LPA is requesting the following documents be updated and submitted by 12/14/24: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required) Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash) Copy of Current Liability Insurance Resident Roster The following deficiency was observed: LPA toured the facility property with the LPA and observed a large storage shed in the yard that had an accordion style door, it was broken and hanging on one side; The shed stored miscellaneous items, including disinfectants/cleaners. Administrator stated they would be fixing this storage door. The Administrator did have a lock on the door, but this was not sufficient security with the door being broken. LPA obtained photos. This deficiency will be cited, 87705 ( f)(2)- Care of Persons with Dementia -The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants, see LIC809D. 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. Appeal rights given to the Administrator. Exit interview conducted with Licensee/Administrator Lailani Cenzon.