Routine inspection·February 15, 2024

At 09:15 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Nickie Perez arrived shortly after. At 09:38 a.m. the LPA conducted a tour of the physical plant with Administrator Nickie Perez to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a residence that consists of two (2) buildings, with ten (10) resident rooms in each building. Building #2 is two stories and the second story is designated solely for staff. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 03/17/2023. At 12:05 p.m. all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings throughout the facility. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen : During the facility tour, the kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are available for residents. Bedrooms: During today’s visit, the LPA observed ten (10) randomly selected resident units. The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Water temperature measured in the restrooms in both buildings ranged between 108.6 degrees Fahrenheit and 118.6 degrees Fahrenheit. Report will continue on LIC809-C. Common Areas: These included the dining areas and living areas. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There were no obstructions and/or tripping hazards throughout the facility. Cleaning supplies and toxins were observed locked and inaccessible. Surrounding Grounds (Outdoors)/Garage : The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The garage is detached and locked at all times. No bodies of water were observed. Infection Control: The community's policies and procedures pertaining to infection control were adequate. Record Review: At 11:38 a.m. a review of facility files was initiated. Facility records are stored in a locked office. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 10/09/2023). The LPA obtained Client Roster, Staff Roster, and Insurance Liability. The LPA reviewed five (5) of twenty-three (23) resident files. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. The LPA identified that all five residents were missing the Consent for Emergency medical treatment form, (LIC 627C). Otherwise, all resident records were in order. The LPA reviewed five (5) of twenty-two (22) staff files. Personnel records and Administrator’s file were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. The LPA identified that three (3) of five (5) staff did not have a total of 20 hours of the annual required training which includes 8 hours of dementia training, and 4 hours which shall be specific to postural supports, restricted health conditions, and hospice care. Interviews: During today’s visit, the LPA conducted six (6) resident interviews and four (4) staff interviews. No concerns voiced during the interviews. Medications: At approximately 3:45 p.m. a medications review was initiated for two out of five residents and the following was observed. The medications were stored in a medication room and med carts which are locked and inaccessible to the residents. During Resident #2 (R#2's) audit, the LPA observed four (4) extra Metoclopramide 5 MG tablets, and two (2) extra Mirtazapine 15 MG ½ tabs based on start dates, and medication quantities documentation on the Centrally Stored Medication and Destruction Record (CSMDR). No change in orders were observed, and no refusals, or other reasons for medicine not being taken were observed on the Medication Administration Record (MAR) by the LPA and Administrator Teresa. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.