Routine inspection·October 21, 2024

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:45 a.m. LPA initially met with staff Noemi Deocampo. Administrator Onyx Pacheco was contacted via phone and arrived shortly at 10:10 a.m. Entrance interview conducted. The LPA, along with Administrator conducted a physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. This facility doesn’t have a staff room, facility provides 24/7 care. The following was observed: Fire extinguishers are fully charged and purchased on 10/21/2024. Hardwired combination smoke detectors and carbon monoxide detectors were tested at 11:45 a.m., and all were functional at the time of the visit. Facility is equipped with two (2) fire doors. At the time of the visit, both fire doors were in operable condition. No fire clearance concerns were observed. Bedrooms: The facility consists of four (4) bedrooms total, of which two (2) are private rooms and two (2) are designated for shared resident use. Bedrooms #2 and #3 are designated for single use and bedrooms #1 and #4 are designated for double occupancy. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Continued on LIC 809-C Continued from LIC 809 Bathrooms: The LPA observed two (2) bathrooms in the facility; one (1) is a shared bathroom for resident's use only, and one (1) is a staff/visitor bathroom. Resident bathroom was clean and sanitary and in operating condition with grab bars and non-skid surfaces. In the staff bathroom, LPA observed under sink an unlocked cabinet. There, LPA saw a bottle of Dove aerosol deodorant and a disposable razor. LPA explained Administrator the importance of keeping these items locked when caring for residents with dementia. Administrator stated that only staff and visitors use this bathroom. Water temperature was measured in the shared resident restroom at 10:56 a.m. and measured at 130.3 degrees Fahrenheit. Kitchen : Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of perishable. LPA observed a low non-perishable food supply. During today’s visit a staff member went to the supermarket and bought extra non-perishable can items. LPA reminded Administrator that non-perishable food shall be maintained for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. Technical advice issued. All knives and cleaning supplies were observed to be locked and properly stored at the time. All cleaning compounds were stored in areas separately from food supplies. At 11:06 a.m. hot water temperature measured 128.9 degrees Fahrenheit. Furthermore, laundry area, was observed between the kitchen and the staff bathroom. There, the LPA observed the washer and dryer and locked cabinets. Inside those locked cabinets facility keeps cleaning supplies, disinfectant wipes and staff and personnel files. Common Spaces: The common areas were checked for cleanliness. At the time of the visit, living room and dining room furniture was observed to be in good condition. Facility maintained a comfortable 71 degrees Fahrenheit. The LPA observed the required postings in the common area. A fireplace was observed to be adequately screened. LPA observed a Ring doorbell at the main entrance. Next to the living room table there is an office space. Medication is kept locked in the office area. Continued on LIC 809-C Continued from LIC 809-C Outdoor Space: The front yard is free of obstructions. Both side gates on each side of the facility were self-latching. LPA also observed a patio in the back yard which had shade and seating areas for residents to enjoy. There were no bodies of water noted. Additionally, LPA inspected the detached garaged. Garage: At 11:15 a.m., LPA enter the detached garage. The garage was observed unlocked. The garage consists of two (2) back-to-back rooms. The first room stored extra incontinence supplies, extra ambulation devices and a fridge. The second room was converted to a bedroom. There was a closet where emergency backpack, emergency food and emergency kits were stored. LPA asked Administrator if garage was modified before fire marshal inspected facility and granted fire clearance in 2023. Administrator stated “No”, adding “here is where staff members will lay to take naps or rest”. Administrator concluded her statement with “modification was made after licensure. LPA requested ADU permits. Administrator explained that home owner has city approved permits for this alteration, however, they are away for the next three weeks and won’t be able to provide permit during today’s visit. LPA discussed to obtain appropriate fire clearance before housing an individual inside the ADU. Additionally, Administrator will have to submit a new sketch along with the LIC200 and permit to Community Care Licensing. Furthermore, LPA discussed any modifications made to the facility should be submitted to the department and requires permits prior to any modifications are completed. Record Review: Began at 1:25 p.m., staff and resident records were reviewed for documents including, but not limited to, health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Three (3) resident records were reviewed. LPA observed that two (2) out of three (3) resident’s needs and service plan form were signed, however fields were incomplete. All other required records were in compliance. At 3:15 p.m., LPA reviewed four (4) staff files; the following was observed. During the physical plant tour LPA observed and individual at 11:17 a.m. inside the detached garage/ADU. Continued on LIC 809-C Continued from LIC 809-C Administrator stated that S1 is a family member taking care of Administrator’s son. LPA requested Staff #1 (S1) personal information. A review of the Guardian system revealed that S1 determination is in process. Furthermore, LPA observed employment forms dated on 09/01/2024 under S1’s name. LPA requested Administrator to ask S1 to leave the facility and explained that S1 can not be in the facility until S1’s background check is cleared. Medication Review: Began at 3:41 p.m. Medications for three (3) residents were observed. Facility is not utilizing the Centrally Stored Medication and Destruction Log (LIC622). Instead, facility is using the Medication Administration Record (MAR). LPA explained that facility does not have to use LIC622 specifically, however information from that form shall be used to help track of every medication. LPA requested an updated LIC500, Resident Roster, Liability Insurance documents and last emergency drill conducted on 10/02/2024. Facility is using the emergency and disaster plan to document date when emergency drill is conducted. LPA explained Administrator that an emergency drill log is required to document the date when drill is conducted, and name of staff was trained. Administrator provided LPA proof of an updated Emergency Drill log. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted, Citations/civil penalties issued /A copy of the report and appeal rights were issued. $500 civil penalty issued