2592 Ciro

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:20 a.m. The LPA was greeted by staff and met with Administrator Mervin Galvez and explained the reason for the visit. The LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. BEDROOMS: The LPA began the inspection with the Bedrooms. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The facility consists of 5 (five) total bedrooms, 4 (four) are designated for resident use with (2) shared rooms and (2) two private rooms and 1 (one) designated staff room. Staff bedroom was locked appropriately. RESTROOMS: The (2) two resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in bathrooms measured between 118.0-120.0 degrees Fahrenheit. KITCHEN: Kitchen knives are stored locked and inaccessible in a drawer to the right of the stove. The supply of dishes is adequate. Appliances in the kitchen were clean and functional. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. COMMON AREAS: The facility is a single-story structure with a large sunroom, dining room and living room. The LPA did not observe any obstructions or hazards. At the time of the visit, the living room, sunroom and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 74 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The LPA observed fire extinguisher along the dining room wall which was last serviced 06/12/2023. Linen closet and locked cabinet containing cleaning supplies and hygiene items was observed in the main hallway locked and inaccessible. **Continued on LIC 809-C** OUTDOOR AREA: The backyard has outdoor covered patio area equipped with furniture for client use. There is a side gate for client use and is single latched. No bodies of water noted. The garage is where the washer and dryer are held, including emergency supply food items and PPE. Cleaning supplies and disinfectants are kept in in the garage. The garage is locked and inaccessible. RECORD REVIEW: At 11:30 a.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention, and Insurance liability. The LPA obtained Client Roster, Staff Roster, and liability insurance. Residents’ records review began at 11:30 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 2:15 p.m.; medications are centrally stored and locked in a mediation cabinet in the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 6, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 12:45 p.m. This will be the first annual since their Pre-Licensing visit on 9/24/2021. Upon arrival, LPA was scanned and greeted at the door by staff, Rosalinda and Rolando. The Licensee, Gilliana Sherman and Administrator, Mervin Galvez arrived shortly after and the reason for the visit was explained. Entrance interview. At 1:20 p.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathroom, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed all knives and sharps locked in a drawer next to the oven inaccessible to residents. Cleaning supplies and toxins were observed locked under the kitchen sink. Medication and facility files were observed in a locked cabinet adjacent to the kitchen. BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed throughout. The bathrooms were measured for hot water; the first bathroom measured at 105.8 degrees Fahrenheit at 1:25 p.m., and the second bathroom measured at 105.3 degrees Fahrenheit at 1:27 p.m. …Report Continued on LIC 809C... …Report Continued from LIC 809... GARAGE AND GROUNDS: The garage is locked and attached to the house. There is another refrigerator in the garage with additional food. The LPA observed a sufficient supply of emergency water and food. The fire extinguisher was observed to be fully charged on 6/07/2022. The facility maintains at a temperature of 75 degrees. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit. COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed two (2) residents in the living room watching television at the time of visit. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff and residents are fully vaccinated and boosted. Staff were observed wearing face masks. No identified staffing concerns. Exit interview conducted. No citations issued. A copy of the report was provided via email.the state’s words, verbatim · CDSS document, Oct 14, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an announced pre-licensing visit to this property at 8:00am on 09-24-2021 and met with Licensee Gilliana Sherman. Entrance interview conducted. The applicant has obtained fire clearance for a total capacity of 6 (six) bedridden clients. Facility currently has five (5) residents of which only one (1) is bedridden. Facility has five (5) bedrooms and 2 bathrooms. Two (2) bedrooms are double occupancy and two (2) bedrooms are single occupancy. Fifth bedroom is for staff. The smoke detectors and carbon monoxide detector were tested and were operational. LPA observed one (1) fire extinguisher in the kitchen to be fully charged on May 17, 2021. The facility has emergency lighting throughout the hallways. LPA observed two (2) first aid kits, one in the living room and the other in the medication cabinet. Both had manual and were complete with alcohol wipes, ice packs, bandages, scissors, tweezers, gauze, and a thermometer. The common living and dining areas are clean and properly furnished with seating, coffee table and a television for resident use. LPA observed three (3) residents seating in the living room watching television. Facility currently has a working landline telephone. All seven (7) exit doors have functioning auditory alarms. All bedrooms, bathrooms, kitchen, and common areas windows have clean window coverings with screens and in good repair. Appliances in the kitchen were clean and all appeared functional. LPA observed two (2) refrigerators, one in the kitchen and one in the garage. LPA observed a sufficient supply of at least seven (7) non-perishable and two (2) days perishable foods. Hot water at the kitchen sink measured at 118.3 degrees Fahrenheit. LPA observed a locked cabinet in the garage and in the hallway where chemicals and cleaning supplies are stored. Also, one designated drawer next to the kitchen sink was observed locked, containing knives and sharps. LPA observed medications to be locked in cabinet next to the refrigerator in the kitchen. Facility records are locked in a cabinet by the dining area. Hallways were free of any obstruction. There are four (4) resident bedrooms that were properly furnished. Single occupancy bedrooms had a bed with clean linens, a table lamp, a nightstand, and adequate lighting. Double occupancy bedrooms had two beds, clean linens, each side had a table lamp, a nightstand, and adequate lighting throughout. (...Continued on LIC 809C...) (...Continued from LIC 809...) There are two (2) bathrooms for resident use. Bathrooms were measured for hot water, first bathroom measured at 106.00 degrees Fahrenheit, second bathroom measured at 105.1 degrees Fahrenheit. Each bathroom was adequately equipped with toilet paper and paper towels, as well as with grab bars and non-skid mats. LPA observed a covered patio area with tables and chairs for resident use. LPA observed rails throughout the backyard for residents. LPA observed two (2) fence gates that self-latch with clear passageways for emergency exit use. LPA observed no bodies of water accessible to residents. LPA observed CDSS PINs posted along with Personal Rights, Complaint Poster (PUB 475), LTCO Poster, and Emergency Exit Plans. No firearms or ammunition will be stored in facility at any time. Comp III was completed in conjunction with the visit. Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA recommendation for licensure. Exit interview conducted. A hard copy was provided via email.the state’s words, verbatim · CDSS document, Sep 24, 2021

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 5 Method: Telephone call with CAB Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by correctly answering identity verification questions. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicants have been advised to transmit signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Sep 10, 2021