Routine inspection (multi-day)·January 22, 2024

At 11:00 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 01/04/2024. The LPA was greeted by Administrator Ken Mahler and informed them of the reason for the visit. Today the LPA conducted a medication audit and finished the record review initiated on 1/04/2024. Record Review: At 11:15 a.m. the LPA observed documentation of Infection Control Plan, Disaster prevention and last fire drill (conducted on 12/19/2023). The LPA obtained Resident and Staff Rosters. The LPA reviewed one (1) out of seventy-nine (79) resident files, the file appeared complete and current. The LPA observed five (5) out of fifty-six (56) staff files which included but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid certification. Out of the five files reviewed, three out of five staff (S1, S3, S4) require first aid certification, In addition, the LPA was unable to identify the completed eight (8) hours of annual medication training nor could the LPA identify annual training for restricted health conditions for two out of the five staff (S1,S2). Medications: At 3:00 p.m. a medication review was initiated for two out of five residents and the following was observed. The medications were stored in medication rooms, which are locked and inaccessible to the residents. During Resident #1 (R#1's) audit, the LPA observed Telmisartan 40MG and Memantine HCL 10MG documented on the Medication Administration Record (MAR) as given on 1/7/24, however the medications were still in the bubble packs. During R#2’s audit, the LPA observed four (4) medications not documented on the Centrally Stored Medication and Destruction Record (CSMDR). 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 Administrator Ken Mahler.