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25 | Licensing Program Analyst (LPA) Adam Hamer conducted a case management visit on today's to check on the welfare of the residents in care. LPA arrived at the facility, spoke with Caregiver Ma Guinto and was granted entry after identifying himself and disclosing the purpose of the visit. Ms. Guinto was not wearing a mask and no screening was done prior to or at any point thereafter during LPA's visit.
LPA conducted a tour of the facility, inside and out. During the tour, LPA observed one ambulatory resident in the living area adjacent to the kitchen (resident #1 - R1), another non-ambulatory resident in the living area (resident #2 - R2), and four (4) residents in their rooms with their doors open (R3, R4, R5 and R6)(see LIC 811 - Confidential Names List). In the kitchen area, LPA also observed that there were medications centrally stored in an open, unlocked cabinet near the refrigerator and in an unlocked drawer underneath the kitchen counter, accessible to R1 who was in the living room area. In the drawer, there were pills in two (2) unlabeled, open plastic containers and other resident medications.
Interviews with staff (S1) revealed that the medicine drawer and cabinet next to the refrigerator were kept open throughout the day and residents' pills are distributed to each resident from the open pill containers.
LPA entered a bathroom next to five of the residents' rooms and observed several containers of various cleaning supplies underneath the sink in the bathroom. The door to the bathroom was unlocked and open prior to LPA entering, and the cabinet was also unlocked and open.
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32 | The facility's mitigation plan states that the facility will require staff to wear face coverings; check visitors for temperature and symptoms upon entering the facility; post signs outside the facility, do screening upon entry, and have a sign in policy upon entry of any visitor. Upon arrival at the facility, LPA observed no signage outside the facility. Upon entry, caregiver Ma did not have a mask on, did not check LPA's temperature, did not require LPA to sign in and did not do any screening for symptoms whatsoever. LPA gave Administrator Encabo an advisory with regard to the facility's not being in compliance with its COVID-19 mitigation plan.
Based on today's inspection, deficiencies were observed and cited in accordance with California Code of Regulations, Title 22 on the attached LIC 809D form. Also, because these were two (2) repeat violations of the same subsections within twelve (12) months, immediate civil penalties were assessed in the amount of $1,000 for each repeat violation.
An exit interview was conducted with Mr. Encabo, plans of corrections were discussed with LPA and developed by the administrator, and a copy of this report, the LIC 809D, LIC 421IM and LIC 811, and Licensee/Appeal Rights (LIC 9058 01/16) were provided to him by email; he expressed that he would send LPA a confirmation email upon receipt of these documents. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
09/10/2021
Section Cited
CCR
87465(h)(2)
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7 | (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. | 1
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7 | Administrator Encabo immediately removed the medications from the areas described and stored them in a locked and inaccessible cabinet in the kitchen area of the facility. Licensee will participate in an outside vendor training with all staff on medication administration and storage, and provide proof of completion by September 10, 2021. |
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14 | This requirement was not met as evidenced by: Based on LPA observations and interviews, the centrally stored medicines were not kept in a safe and locked place and were accessible to a resident. This posed an immediate health risk to one (1) out of six (6) residents in care. | 8
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14 | This is a repeat violation for the same subsection within one year and an immediate civil penalty was assessed. |
Type A
09/10/2021
Section Cited
CCR87309(a)
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7 | (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. | 1
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7 | Administrator Encabo immediately removed the cleaning supplies from the cabinet and stored them in a secure location inaccessible to residents. Licensee will also participate in an outside vendor training with the proper storage of cleaning solutions and other dangerous items, and provide proof of completion by September 10, 2021. |
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14 | This requirement was not met as evidenced by: Based on LPA observation and staff interviews, Licensee did not ensure that cleaning supplies were inaccessible to resident in care. This posed an immediate safety risk to one (1) out of the six (6) residents in care. | 8
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14 | This is a repeat violation for the same subsection within one year and an immediate civil penalty was assessed. |