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25 | Licensing Program Analyst (LPA), Dina Alviso, conducted a Required-1 Year inspection and met with Barbara Santos, caregiver. Caregiver contacted the Licensees/Administrators Joy and Manuel Ortega, who arrived a short time later. The inspection is focused on the Infection Control procedures and practices of this facility.
Facility has an approved dementia plan of operation. There is an approved hospice waiver for four (4) residents. Fire clearance is approved for six (6) non-ambulatory, which includes one bedridden clearance (RM #6.) Fire extinguishers, two (2), were serviced and tagged as required, expires December 14, 2023.
There were six(6) residents in care at the facility during this inspection. Four(4)) residents are on hospice care. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened twice daily, and observed for any changes, all information is logged.
Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents and staff that do not handle medications. All exit alarms were on exit doors and working properly.
Continued on LIC809C.... |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
01/25/2023
Section Cited
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7 | 87705(f)(1)(2) Care of Persons with Dementia- The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).-Over-the-counter medication, nutritional | 1
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7 | Licensee to ensure medications are locked up and inaccessible to residents in care at all times, and others that don't handle medications. Licensee to ensure tools and other items that pose a risk to residents are locked and |
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14 | supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by LPA's observation-knife blade tool left on a foot stool in the livngroom-medication keys were hanging in the medication closets doorlock/doorknob.This is a risk to health & safety and/or personal rights to residents in care. | 8
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14 | inaccessible to residents in care. Hold an in-service traiining with all staff regaridng locking and securing medications and tool/ items that pose a risk to residents, submit proof of training by 2/1/23. Submit plan of correction by /25/23. |
Type A
01/25/2023
Section Cited
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7 | Personal Rights 87468.1(a)(2)- Residents in assited living.-ensuring personal rights are not violated at any time. This requirement is not met as evidenced by: LPA's observations during the inspection. | 1
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7 | Licensee to ensure the staff wear masks at all times as required, ensuring residents personal rights, and health and safety are not violated in any way. |
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14 | Caregiver Barbara Santos was observed not wearing a surgical mask as required. Staff held back from opening the door to let the LPA in as they were trying to get a mask on.This is a risk to health & safety and/or personal rights to residents in care. | 8
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14 | Hold an in-service traiining with all staff regaridng required mask wearing by staff. Submit proof of training by 2/1/23. Submit plan of correction by /25/23. |