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25 | Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with caregiver Alicia Sical-Castenada, who was informed of the purpose of the visit. At the time of the visit there was one (1) staff and three (3) resident present. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:
Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Facility pool had a locked gate. Detergents, cleaning solutions, and sharp and dangerous objects were observed to be locked and inaccessible. The smoke detector and carbon monoxide was operational, and the hot water temperature met department requirements. Facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Records review revealed Licensee has not paid their annual fee since 2021. A deficiency cited under Title 22 Regulation 87156(a) will be issued. LPA reviewed two (2) staff files and training. Records review of Staff One (S1) and Staff Two (S2) did not have updated CPR/First Aid training in their file. Last documented training completed for CPR/First Aid for S1 and S2 was in 2019. A deficiency cited under Healthy and Safety Code 1569.618(c)(3) will be issued. All staff have the required personnel records on file and criminal record clearance. Two (2) resident files were reviewed and possessed all required paperwork which included Admissions Agreement and Physician's Report. Resident medication was centrally stored and locked in a cabinet located in the kitchen. Facility had a centrally stored medication list dated 03/14/2024 for Resident One (R1) that had inconsistencies with the medication available at the facility A deficiency cited under Title 22 Regulation 87465(a)(6) will be issued. LPA reviewed the facility's emergency and disaster plan. All facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items. Fire extinguishers were fully charged and inspected. Facility did not have written documentation of quarterly disaster drills being conducted in the year of 2024. A deficiency cited under Healthy and Safety Code 1569.695(c) will be issued.
An exit interview was conducted where a copy of this report, LIC 809-D, LIC 811, and appeal rights was provided to caregiver Sical-Castenada. |