Routine inspection (multi-day)·August 2, 2023

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a continuation to a required annual visit at 9:45 a.m. The LPA was greeted by staff and informed them of the reason for the visit. This is an annual continuation, which began on 06/19/2023. RECORDS: The LPA continued a records review today beginning at 10:00 a.m. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The LPA continued a records review of staff associations that compared the Licensing Facility Personnel Report Summary dated 6/19/2023 and 8/1/2023 against the facilities most recent LIC 500 dated 3/22/2023 and Guardian. The following was noted: 7 staff (S1, S2, S3, S4, S5, S6, S7) were found not to be associated to the facility. Files contained all required forms however Administrator indicated that staff are usually associated following fingerprinting by the fingerprinting agency and that staff who have been working here for a long period of time were erroneously separated form the facility. LPA advised the Administrator that it is their responsibility to ensure that all staff who are employed are reflected on the association list prior to working at the facility. Facility Personnel Reports are provided to the facility automatically on a yearly basis for review however, Administrator was reminded that they may contact licensing for an updated facility personnel report when they need too. The report is to be used to not only advise the department of any staff who are no longer working at the facility but to also verify that everyone who is working is reflected on the list. S1, S2, S3, S4, S5, S6, S7, have been working at the facility prior to 2021 and Administrator was in possession of a Facility Personnel Report dated 4/7/2021. Civil penalties were assessed. Residents’ records review began at 12:00 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. MEDICATIONS: The LPA audited five (5) resident files. The following is observed: medications are labeled and checked for expiration dates. For 1 out of 5 residents (Resident #1), the facility did not administer day 1 of the new bubble pack 8/1/2023 Digoxin as prescribed by R1’s physician. All medications are properly documented on the centrally stored medications and destruction record for 5 out of 5 residents. INFECTION CONTROL : Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.