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32 | Continued from LIC809
LPA observed that a window in a resident's room needed replacing. Per LPA observation, the window was being propped up by a fake piece of fruit. Further observation showed that the window was loose and could not withstand its weight when opened (see technical violation, LIC9102, regulation 87303(a)). LPA observed that some resident rooms had garbage cans with lids, while other resident rooms did not have garbage cans with lids (see technical violation, LIC9102, regulation 87303(f)(3)). LPA also observed prepoured PM medications in a locked cabinet. Per conversation with Licensee and Staff Member, the PM medications were poured this morning. Review of visit conducted on 06/01/2023 indicated that the facility was issued a technical advisory and therefore was aware that pre-pouring medication was against regulation (deficiency cited, see LIC809D, regulation 87465(h)(5)).
Facility's fire extinguishers were last inspected May 2024. Smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted May 2024.
At approximately 11:30AM, LPA reviewed staff files, resident files, and resident medications. Review of staff files showed that Staff Member 3 (S3) was missing their Health Screening (LIC503) report and proof of negative TB test. 3 of 4 staff members did not have annual 2023 training completed (deficiencies cited, see LIC809D, Regulation 87411(f), and Health and Safety Code, 1569.625(b)(2)). Per discussion with Licensee, all staff have been signed up for online training. 3 of 4 staff files had current First Aid and CPR certification. Per discussion with Staff Member 1 (S1), their certification card is at home but they always work with Staff Member 2 (S2) at the facility. Review of S2's file indicated that they had current first aid/cpr certification (see technical violation, LIC9102, 1569.618(c)(3)). Review of resident files showed that 3 of 9 resident files were missing their reappraisal assessments. Of the 9 residents, 2 residents with a diagnosis of dementia were missing updated annual Physician Reports. 9 of 9 resident files were missing their Needs and Services Plan. 1 of 9 files was missing their Pre-Appraisal Assessment (deficiencies cited, see LIC809D, regulation 87705(c)(5), regulation 87467(a)(2), and regulation 87467(a)). Licensee understands that Pre-Appraisal assessments should be conducted prior to residents moving into the facility. Licensee also understands that assessments and appraisals should be conducted annually for residents with a dementia diagnosis. LPA reviewed 4 of 9 resident medications. During review, LPA observed that some medications were not centrally stored as required. LPA observed that some medications were either not logged or had incorrect dates logged (deficiency cited, see LIC809D, regulation 87465(h)(4)).
Administrator Certificate for Luningning (Bot) Alicdan (6010428470) expired 10/18/2023. Review of Guardian's website showed that Licensee/Administrator's name is not on the pending list or active list. Per Guardian website, renewal applications are being reviewed for the week of 11/06/2023. Licensee informed LPA that they submitted payment for their renewal in 2023.
Continued on LIC809C
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