Routine inspection·September 6, 2024

At 10:15 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and a resident's family member and informed them of the reason for the visit. Administrator Maria Ayala arrived approximately at 11:00 a.m . When the LPA arrived they observed staff #1 and a resident's family member (F1), who is not finger-printed cleared at the dining table going through resident medication records. F1 proceeded to put all files away in the hallway closet where the files and resident medications are stored. At 10:20 a.m. the LPA conducted a tour of the physical plant with staff 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 six (6) resident bedrooms, two (2) resident restrooms, and one (1) staff restroom. The LPA observed fire extinguishers which were fully charged and last purchased in July 2024. 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. Kitchen : The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Snacks and beverages are always available for the residents. Knives are stored in a locked closet, and cleaning supplies are stored in locked cabinet, and in the locked garage. 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. Starting at 10:30 a.m.,the LPA observed the auditory alarms in the exist doors of rooms #1, #3 and #6 to not be operable. At 10:32 a.m. the LPA observed the exit door in room #3 blocked with an arm chair. At 10:39 a.m. the LPA observed the exit door in room #6 blocked with a walker, and chairs. Upon observation, staff removed items from the exit doors. 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 11:40 a.m. water temperature in resident’s restroom in room #6 was measured at 135.3 degrees Fahrenheit. At 11:43 a.m. water temperature in the common restroom was measured at 135.5 degrees Fahrenheit. At 11:48 a.m. the water temperature in the kitchen measured at 136.6 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 first living room, which is covered with a screen. At 10:33 a.m. the LPA observed the light in the hallway leading to the common restroom inoperable. The garage: The LPA observed the garage where additional supplies and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in the garage. The garage is locked. 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. The LPA observed the outdoor furniture with spider webs and dust. Record Review: At 12:38 p.m. a review of facility files was initiated. The LPA reviewed four (4) out of seven (7) staff files. The following was observed: Administrator's file was missing, and all staff records reviewed did not have the required annual training, and three staff did not have a current 1st aid/CPR certificate. In addition Staff #2 (S2) had a Health screening (LIC503) that belong to another staff with their name white-out and S2's name written over. Upon observation the Administrator stated that about a month ago certain staff and residents files had been stolen or altered by previous employees who no longer work at the facility. However the incident was never reported to CCL. The LPA reviewed five (5) out of six (6) resident files. The following was observed: One out five residents did not have TB results on file, otherwise all files were complete. Report will continue on LIC809-C (3rd page). Medication Audit: At 3:20 p.m. a medication audit for two (2) residents was initiated. The following was observed: The medications were stored in a locked closet which is locked and inaccessible to the clients. During Resident #1 (R#1's) audit, the LPA observed the quantity for all medications not documented on the Centrally Stored Medication and Destruction Record (CSMDR) and Bupropion medication not recorded at all. In addition, according to the start date on the CSMDR, and the quantity on the medications prescription label R1's Levothyrozine Sodium 25mcg should have seventeen (17) tablets on the bubble pack, however the LPA observed twenty-three (23) tablets on the bubble pack. During R#2’s audit, the LPA observed an excessive amount of extra medications stored in the garage, which the administrator stated they did not know what to do with as they were extra medications. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit inter view conducted and copy of the report and appeal rights provided to Administrator Karina Rosales Antig.