Routine inspection·July 24, 2024

Licensing Program Analysts (LPAs) Erica Mosley and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:52AM. LPAs were greeted by staff who contacted Licensee/Administrator Mike Trejo who arrived at the facility at approximately 10:10AM. Entrance interview conducted. Beginning at 10:20AM, the LPAs, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Combination hardwired smoke/carbon monoxide detectors were tested at 05:44PM and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 06/28/2024. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. Facility does have an in-ground pool which was observed to be properly fenced and locked inaccessible to residents in care. Facility has two total gates, both gates were observed to be self-latching and closing, however the side with an appropriate pathway for non-ambulatory residents was observed to have multiple items in the walkway, including an unused bed frame and propane tanks. COMMON AREAS : This includes the living room and dining room areas. LPAs observed common area to be clean and properly furnished at the time of the visit. Fireplace was noted to be screened and inaccessible to residents. KITCHEN : The LPAs observed the kitchen/dining area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable Report Continued on LIC 809-C food and emergency water. The LPAs observed one designated drawer where knives and sharps are stored locked and inaccessible to residents. Medications and first aid supplies were locked in a large cabinet in the kitchen area. LAUNDRY : The laundry room is located adjacent to the kitchen. Laundry supplies and chemicals are stored in the locked laundry room, inaccessible to residents in care. There was an additional staff restroom located in the laundry area. BEDROOMS : There are 4 (four) bedrooms in the facility; 2 (two) are designated for shared resident use and 2 (two) are for private resident use. At 10:37AM, LPAs observed Resident #1 (R1) and Resident #2 (R2) residing in Room #4. R1 has full bed rails on their bed, but is not on hospice care at this time. LPAs observed fire clearance for Bedroom #4 is for ambulatory only. R1's physician's report indicates they are non-ambulatory and R2's physician's report indicates they are bedridden, although Administrator indicates R2 is non-ambulatory and LPAs observed R2 sitting at the kitchen table unassisted upon arrival at the facility. All 4 (four) resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. BATHROOMS : There are two (2) bathrooms for resident use, one (1) of which is a shared resident restroom located in the hallway and one (1) is a private resident restroom. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in both restrooms and was observed to be within the required range. RECORD REVIEW: Began at 11:05AM. 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. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs spoke with the Administrator regarding the facility's infection control policies and reviewed the facility's emergency disaster plan. The facility does not have a documented infection control plan, only a COVID mitigation plan. Emergency disaster plan was complete and reviewed annually. Emergency disaster drills are conducted quarterly, with the last drill documented on 03/23/2024. Report Continued on LIC 809-C MEDICATION REVIEW: Began at 05:19PM. Medications for 2 (two) residents were observed. One (1) resident (Resident 3 – R3) had PRN (as needed) medications prescribed, however the Administrator indicated there is no document on file from R3's physician indicating how they determine their need for PRN medication. Further, R3's hospice nurse indicated R3 should take the PRN medication daily, but R3's physician did not document the change in order. INTERVIEWS: LPAs interviewed 1 (one) staff and attempted to interview 2 (two) residents. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Civil penalty issued in the amount of $500. Licensee was advised that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.