Routine inspection·December 8, 2023

At 09:00 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrator Assistant Johnna Udden and informed them of the reason for the visit. Administrator Helen Rose T. Busch arrived shortly. At 09:15 a.m. the LPA conducted a tour of the physical plant with the Administrator 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 single-story residence that consists of four (4) resident bedrooms, one (1) staff room, and three (3) restrooms. The LPA observed one (1) fire extinguishers which was fully charged and last serviced 10/16/2023. At 9:25 a.m. all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. 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. 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 always available for the residents. At 9:17 a.m. the LPA observed a pair of scissors inside a drawer of the kitchen island, and a pair of kitchen scissors in the dish drying basket next to the sink. Upon observation, staff locked away both pairs of scissors. Bedrooms: 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. Report will continue on LIC809-C. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 09:28 a.m. water temperature in residents restroom was measured at 120 degrees Fahrenheit. A conversation was held with the administrator of best practices to ensure water temperature does not exceed 120 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen. The facility maintained a comfortable temperature of 68 degrees. There were no obstructions and/or tripping hazards throughout the facility. The garage: The LPA observed the garage, where the washer and dryer are held, and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. The garage is not locked. At 9:51 a.m. the LPA observed a box labeled “Tools” with an assortment of tools such as pliers and a hammer. The LPA observed power tools, and paint in the garage as well. Surrounding Grounds (Outdoors) : The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. Infection Control: The home has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The home’s policies and procedures pertaining to infection control were adequate. Medications: At 10:01 a.m. a medication review was initiated, and the following was observed. Medications are centrally stored and locked in a cabinet in the kitchen inaccessible to residents in care. During Resident #1 (R#1's) audit, the LPA observed Donepezil HCL not properly documented on the centrally stored medication and destruction log, as the expiration date, date filled, and refills did not match the prescription label. During R#2's audit, the LPA observed Levothyroxine not properly documented on the centrally stored medication and destruction log as the strength, date filled, and expiration date did not match the prescription label. During R2’s med audit, the LPA also observed a bottle of Diltiazem CD with the expiration date of 11/2/2023, and observed Quetiapine not properly documented as there was no record of it being administered in the mornings, and per the prescription it should be administered every morning and at bedtime. Upon observation, staff documented the correct information. Report will continue on LIC809-C. Record Review: At 11:20 a.m. a review of facility files was initiated. The LPA reviewed five (5) out of five (5) resident files, and the following was observed. Two out of five residents (R3,R4) do not have Consent for medical treatment forms LIC627C in their files. One out four residents (R3) did not have a Tuberculosis result on file. The LPA reviewed five (5) of five (5) staff files. The LPA reviewed five staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid/CPR cards. All files were complete. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 11/01/2023). The LPA obtained a Client Roster, Staff Roster, and copy of Insurance liability. I nterviews: The LPA conducted two (2) staff and two (2) resident Interviews. No immediate concerns were voiced. 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 Helen Busch.