Post-licensing visit·September 6, 2024

On 9/6/2024, Licensing Program Analyst (LPA) Hansen conducted an unannounced post licensing inspection for this facility and was welcomed by staff Magela who contacted by telephone Licensee Roxana Galo that arrived shortly after. Administrator Elia Cuevas was unable to attend. This RCFE facility with the capacity of 6 nonambulatory, currently provides care for two (2) residents one of which with a diagnosis of dementia and neither of which are receiving hospice services. Facility has an approved Hospice Waiver for 2. At approximately 8:35 AM LPA conducted tour of the facility with staff, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. The one Fire Extinguisher was found to be last serviced on 8/21/2023 at the time of the visit and reading is not showing fully charged (see TA LIC 9102). There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. When LPA entered facility at 8:30 AM observed (see pics) door with signal turned off and propped open from kitchen to garage where toxins and cleaning supplies are stored in cabinet in garage with locks that do not work as well as window cleaner in unlocked cabinet under kitchen sink all accessible to residents in care (see pics & LIC809-D). There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. LPA tested 6 smoke alarms and 2 carbon monoxide detector and were all found to be in working order. Medication and file storage is stored in a secured cabinet located in Administration area adjacent to the kitchen. Working auditory alarms are placed on all exits. Continued on LIC 809-C File Review began at 9:35 AM: A sample review of two residents & three staff records as well as two resident’s medications was conducted. LPA learned that 2 out of 2 residents have updated Appraisals as well as medical assessments. As per sample review of staff records, staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions; In addition, Direct care staff have received the additional training requirements although are not logged (see LIC9102 TA); LPA was also provided required proof of CPR & 1 st Aid certification. Medication Audit began at 11:15 AM: Medications were centrally stored in locked cabinet in Admin area adjacent to kitchen. LPA observed medications of 2 out of 2 residents were found to be given according to physicians’ directions. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to have all medications entered for residents. LPA reviewed Licensing Information System (LIS) with Administrator who stated that is corrected and updated at this time; no need to change any of the information. Disaster Drills have not been conducted Technical Advisory given, although should be conducted quarterly and in different shifts. Facility has not obtained required Liability Insurance and is being cited today (see LIC809-D). Administrator Certificate for administrator Elia Cuevas # 6057784740 expires 1/4/2025. 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.