Routine inspection·November 6, 2024

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at approximately 9:00 A.M. When the LPA arrived, there was three (2) staff members and three (3) residents present. The LPA was greeted by Caregiver, Jonie Nay Del Rosario. LPA informed the reason for the visit. Caregiver contacted the Administrator by phone, Amelita Gagarin. At 9:20 A.M., Administrator and back up Administrator Jovelito Gagarin, arrived at the facility. At 10:14 A.M. Administrator received a phone call and had to exit annual visit. Back-up administrator is authorized to sign today’s report. Entrance Interview. Beginning at 9:43 A.M., the LPA, along with Administrator and back-up 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: KITCHEN : Kitchen appliances appeared to be in operable condition. At 9:45 A.M. hot water measured at 111.8 degrees. Cleaning supplies were stored in a locked cabinet under the kitchen sink. The facility has a sufficient supply of perishable and non-perishable food. At 9:57 A.M., LPA conducted a review of expiration dates on product labels. The LPA observed that three (3) items were past their expiration date. Back-up Administrator discarded all three (3) items during today’s visit. Technical Advice Issued. Continued on LIC 809-C Continued from LIC 809 Between 9:47 A.M. and 9:52 A.M. LPA asked Administrator to show where knives are stored. Back-up Administrator opened the dishwasher and slid open an interior drawer containing all sharps. Back-up Administrator stated that residents don’t use the dishwasher and are unaware of where knives are stored. During a check of the kitchen drawers, the LPA observed an approximately 5-inch kitchen knife in the utensil’s drawer. LPA explained that per regulation knives and sharps shall be locked and inaccessible to residents in care. LPA requested Administrator and back-up Administrator to secure all sharps immediately. Going forward, staff will store knives and sharps in the locked hallway cabinet where medications and First aid kit are kept. BEDROOMS: There are 5 (five) bedrooms total, of which 2 (two) are private rooms, 2 (two) are designated for shared resident use and 1 (one) is a staff room. All bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. BATHROOMS: The facility has 2 (two) bathrooms, 1 (one) is designated for shared resident use and 1 (one) 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 10:08 A.M. and 11:18 A.M. hot water temperature was measured and measured within the required range. LAUNDRY ROOM: LPA observed laundry room to be locked. Cleaning supplies and hygiene products were observed to be locked in a hallway cabinet and properly stored at the time of the visit. GARAGE: The garage is attached to the house. Garage was observed to contained extra mobility aid supplies, decoration, cleaning supplies and storage. Emergency water was observed in the garage. 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. However, Long-Term Care Ombudsman poster was covered by Community Licensing forms. The LPA requested that the Administrator remove these forms and ensure that the poster remains free of obstructions at all times. Technical Advice issued. A fireplace was observed to be inaccessible to residents in care. The facility maintained a comfortable temperature of 69 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. Continued on LIC 809-C Continued from LIC 809-C There is also an ample supply of linen, towels and paper products. LPA observed night-lights were present in the hallways. On the hallway a locked cabinet was observed, there facility keeps staff and resident files and medication. Smoke and carbon monoxide detector were tested at 11:03 A.M. and both were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 09/20/2023. During today’s visit back-up administrator got the kitchen’s fire extinguisher serviced by Service-Pro Fire Protection. New annual service date reads 11/06/2024. 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 one side gate. LPA observed side gate to be self-latching and closing with clear passageways for emergency exit use. RECORD REVIEW: Between 11:19 A.M. and 12:27 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 reviewed were complete and contained all required documents. Five (5) staff files including Administrators were reviewed. LPA observed that Staff #1 (S1) and Staff #2 (S2) were hired in 08/2024 but are not CPR training was not complete. Additionally, LPA observed missing ID form (LIC 501), Job application, Health Screening form (LIC 503) and Criminal Record Form (LIC 508) for S1. During today's visit S1 completed LIC 508, LIC 501. MEDICATION REVIEW: At 12:42 P.M. LPA started medication review. Medications for three (3) residents were observed. Medications are centrally stored and locked in a hallway cabinet. 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. residents' medications are maintained and administered in compliance with regulation. Continued on LIC 809-C Continued LIC 809-C 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 10/05/2024. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.