Routine inspection·November 4, 2024

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:20 A.M. LPA initially met with facility staff. Licensee/Administrator was contacted via telephone and arrived at the facility at 10:45 A.M. Entrance interview conducted. Beginning at 10:52 A.M., the LPA, along with Licensee/Administrator toured the 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. The following was observed: COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be inaccessible to residents in care. The facility maintained a comfortable temperature of 70 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. All hard-wired combination smoke alarm and carbon monoxide detectors were tested at 11:39 A.M. and function properly at this time. Fire extinguishers were observed to be fully charged and purchased during today’s visit. The two (2) common living and dining areas are clean and properly furnished. During the inspection, the LPA observed in the common area located next to room #4, room #5 and the staff room a television that was turned on. Additionally, the LPA noted Resident #1 (R1), sleeping on the facility couch, despite the resident having their own room. It was also observed that the resident’s room does not have a television. When questioned, Administrator stated that resident prefers not to have a television in their room. LPA observed cameras in the common areas only. Continued on LIC 809-C Continued from LIC-809 BEDROOMS: The facility has seven (7) bedrooms total; six (6) are designated for resident use and one (1) is designated for staff use. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: The facility has four (4) bathrooms, one (1) is located in the hallway and is designated for shared use and three (3) are for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 10:52 A.M. and 11:25 A.M. hot water was measured in all resident restrooms and measured within the required range of 105 - 120 degrees Fahrenheit. LAUNDRY ROOM/GARAGE: Adjacent to the kitchen is a locked garage. Inside the locked garage LPA observed a washer and dryer. Cleaning supplies and hygiene products were observed to be in an unlocked cabinet. According to Administrator the cleaning supplies and detergents are not locked in the cabinet within the garage because the garage itself has restricted access. Both entry doors leading to the garage are kept locked at all times, ensuring that residents cannot enter the area. Only authorized staff members have keys to access the garage, which maintains inaccessibility to residents. Additionally, LPA observed three (3) extra fridges with extra food for residents and staff, extra cleaning and PPE supplies, and storage. Emergency food and water was observed in the garage. OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be free of hazards. There were no bodies of water noted. Facility has two total gates; both were observed to be self-latching and closing with clear passageways for emergency exit use. A locked shed containing gardening tools was observed. KITCHEN : The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present. Kitchen appliances appeared to be in operable condition. Knives were observed to be stored in a locked drawer and cleaning supplies were locked under the kitchen sink. Adjacent to the kitchen is a locked cabinet for medication and file storage, as well as first aid kit. At 11:33 A.M. hot water measured at 115.8 degrees Fahrenheit. Continued on LIC 809-C Continued from LIC 809-C RECORD REVIEW: 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. At 12:37 P.M. LPA reviewed six (6) resident records. The following was observed, Resident #1 and Resident #2 resident’s admission agreement were incomplete and didn’t have signatures. Resident #2 did not have TB test done before admission, Resident #3 did not have a complete consent forms nor pre-appraisal forms. At 2:14 P.M. LPA reviewed five (5) staff files including Administrato'sr. LPA observed Staff #1 (S1) and Staff #2 (S2) missing signatures on the Personnel record form (LIC501) and missing Health Screening report (LIC503). However, TB test results were on file. Additionally, LPA observed Staff #1 and Staff #4 without proof of valid CPR certificate. MEDICATION REVIEW: At 2:55 P.M. medications for six (6) residents were observed. Medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. All six (6) residents' medications were observed to be maintained and administered in compliance with regulation. During today's visit, LPA gathered the following items: Personnel Record (LIC500), Facility Roster (LIC9020A). A copy of the facility's liability insurance. Emergency disaster drills are conducted quarterly, with the last drill documented on 09/25/2024. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Civil Penalties issued in the amount of $100. Failure to correct the deficiencies may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.