Routine inspection (multi-day)·August 17, 2023

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 06/15/2023. The LPA was greeted by Med Tech Dora Islas and informed them of the reason for the visit. Office Manger Angelica Arambulo arrived shortly. Today the LPA conducted a file review, a medication audit, four (4) resident and three (3) staff interviews. Record Review: At 10:45 a.m. a review of facility files was initiated. The LPA reviewed five (5) out of sixteen (16) Resident Files. The following was noted: Resident #1’s (R1’s) file was observed to be missing their functional capability assessment, R2’s file was observed to be missing a preplacement appraisal, and R3 and R4’s file was observed to be missing their personal rights (LIC613). The LPA reviewed five (5) of twenty-one (21) staff files. The following was noted: One staff (S1) file out of five was observed to be missing a first aid certificate, health screening, and documentation of Tuberculosis. Four out of five staff files (S1, S2, S3, S4) were missing four hours of training which shall be specific to postural supports, restricted health conditions and hospice care. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 5/26/2023). The LPA obtained Resident and Staff Rosters. Medications: At 1:30 p.m. a medications review was initiated. The following was observed: R1’s Expiration date and date filled for Nifedipine ER did not match the Facility Centrally Stored Medication and Destruction Record (CSMDR), R2’s expiration date and date filled for Losartan POT and Memantine HCL did not match the CSMDR, and R3’s CSMDR records were observed to be missing. R3’s Risperidone medication was counted in front of the LPA and was observed to have three more pills than needed based on the quantity on the medication’s label, in addition on the Medication Administration Record, medication for August 14, 2023 was unaccounted for. Upon observation, Med Tech Dora initiated correcting all of the missing information for residents (R1,R2, and R3). I nterviews: During the visit the LPA conducted four (4) resident Interviews and three staff interviews 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 to Office Manager Angelica.