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32 | The auditory devices, smoke detectors, carbon monoxide detectors were tested and in operating condition. LPAs toured the outside grounds. There were sufficient seating and shading for the residents, and the walkways were clear of hazards. One out of the two exit gates were not self-closing and self-latching.
LPAs reviewed six residents’ files. No pre-appraisals and re-appraisals were observed for four out of the six residents. One Physician's Report was not present and the second was not current. Interviews were conducted with six residents and two staff. The medications and the Medication Administration Records (MARs) were reviewed for six residents. No discrepancies noted. Staff files were not available for review at the time of inspection.
The following items were reviewed: Complaint Poster (PUB475) in the required size, food menu, activities, resident's rights, Emergency Disaster Plan (LIC610D), and the Infection Control Plan.
The following items were advised: to purchase or service the fire extinguishers annually, ensure toxins/sharps are secured, audit/organize/label the expiration dates of the pantry items, repair one exit gate to ensure it self-latches unassisted, to maintain, organize, the resident files and the required documents annually or as needed upon change of condition with respect to the Physician's Reports, Reappraisals, and to obtain a doctor's order for the half rails for Resident #1 (R1).
Based on LPAs' observations, one deficiency will be cited today as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. The remaining deficiencies will be addressed on the continuation inspection at a later date due to time constraints in addition to the review of staff files.
An exit interview was conducted with Administrator Baabak Sharifan, and a copy of this report along with the LIC9099C, LIC9099D, and the appeal rights were provided at the end of the visit.
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