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32 | COMMON AREAS: This includes the living room and dining room areas. LPAs/LPM observed common area to be clean and properly furnished at the time of the visit. At 01:37 PM the supply closet in the dining room was observed to be unlocked and contained cleaning supplies and medications. Exit doors contain alarms and were functional at the time of the visit. LPAs/LPM observed video surveillance cameras in the common areas with an audio component. The administrator was advised that they are not allowed to have an audio component, therefore administrator agreed to remove the surveillance cameras. Medications and records were observed in locked cabinets in the living room area.
OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. An outdoor shed was observed to be locked and inaccessible to residents.
MEDICATION REVIEW: LPAs/LPM were unable to conduct medication audit due to residents' medication not being stored on the Centrally Stored Medication and Destruction Record.
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. Five resident files reviewed were found to be complete, although record review and an interview with the Administrator revealed Resident #1 (R1) needs assistance with all activities of daily living and does not have an approved exception on file. Staff record review revealed, S1 did not have a facility file and was not associated to the facility. The Administrator also did not have proof that Staff #2 (S2) was associated or had criminal record clearance. S2 left the premises after the LPAs/LPM arrived. Administrator's certificate was observed to be current with an expiration date of 01/24/2025.INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 05/23/2024.
Administrator was advised that licensing fees are due today 06/27/2024 and was provided the PIN to pay the fees online.
Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.
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