G.M. Rojo Guest Home

Type of visit: Required - 1 Year

On April 27, 2023, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to conduct a required annual inspection. LPA met with , Administrator Madelyn Rojo and explained purpose of inspection. Prior to initiating the inspection LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: mask. Maria and LPA completed the inspection tool questionnaire with no issues or advisories to report. LPA observed the following: Administrator certificate is valid. First aid kit fully stocked and ready for emergency use. Fire extinguishers fully charged. Common areas were clean and in good repair. Bedrooms had required furniture and lighting. Facility has required (2) day perishable supply of food and (7) supply of non-perishable food. Water temperature measured 113 degrees F. Medication was properly stored and locked away. LPA reviewed 2 resident files and 2 staff files. Resident's Records reviewed indicated emergency contacts, Assessments, Admission Agreements and Physician's Reports were all current and up to date. Staff records reviewed revealed current First Aid & CPR certificates, Health Screenings and Emergency Contacts and background checks were all up to date. The facility is conducting staff training as required. To continue see 809-C As a result of this visit, no deficiencies were cited, per Title 22 Regulations, Division 6. Administrator submitted the following documents to update the Regional Office files on Community Care Licensing -LIC 500 facility personnel or staff schedule -LIC 610 emergency disaster plan -LIC 308 designation of administrative responsibility -copy of liability insurance -updated facility sketch The will be due May 27, 2023 Exit interview conducted and a copy of this report given to Madelynthe state’s words, verbatim · CDSS document, Apr 27, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/26/22 to conduct a case management inspection to follow up on a recent medication error at facility. LPA met with facility administrator Madelyn Rojo and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and contacted facility and completed a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn surgical mask. LPA was screened by facility staff upon entry. During record review and staff interviews, it has been revealed that facility kept the proper record for centrally stored medications for all residents however there was a missing signature on MAR sheet for R1s medication after the medication has been administered. Facility will implement double signature sheet for medication administration to avoid such errors in future. No citations issued today. Exit interview conducted with administrator. Copy of the report provided.the state’s words, verbatim · CDSS document, Oct 26, 2022

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Michael Hood met with Administrator, Madelyn Rojo, to conduct a case management visit. The purpose of today's visit is to follow up on a Title 17 review conducted at this facility by Alta California Regional Center (ACRC) on 03/28/22. A Facility Action Report (FAR) was generated by ACRC from the Title 17 review. CCLD received a copy of the FAR and it was noted that the facility was cited for violations that are in both Title 17 and Title 22. CCLD's visit today is to address the issues found in the FAR that apply to Title 22. Based on the FAR report, the facility violated the following Title 22 violations: Based in ACRC's inspection, centrally stored medication documents did not accurately reflect the quantity and expiration date for multivitamins. As a result of today's inspection, a deficiency is cited pursuant to California Code of Regulations, Title 22, Section 87465(h)(6) regarding centrally stored medication documents. Deficiencies are listed on 809-D. Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 15, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(6) · Plan of correction due date: Apr 16, 2022

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year. This requirement is not met as evidence by: Based on FAR received by ACRC regarding inspection conducted on 3/28/2022, facility did not ensure that centrally stored medication documents were accurate, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2022

Plan of correction: Administrator will create a written plan to ensure medications are logged into the Centrally Stored Medication Log correctly. Administrator will also schedule on-the-job training for April, May, and June 2022 regarding medication documentation. Facility will submit to LPA information regarding training, including time and date of training and training material, by POC due date of 4/16/22.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 4/15/2022 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Madelyn Rojo, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols and the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 3 bedrooms and 1 bathroom for residents, common area, dining room, food supply, garage, and outdoor area. LPA and Administrator completed the infection control domain. During inspection, LPA observed that storage used to hold medications could still be opened when locked. During inspection, facility moved medications to a locked area and storage previously used for medications was repaired. As a result of today's inspection, a deficiency is being cited pursuant to California Code of Regulations, Title 22, Section 87465(h)(2) regarding storage for medications. Deficiency is listed on 809-D. Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. The Administrator’s signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Apr 15, 2022

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Michael Hood arrived at the facility unannounced on 12/22/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Administrator, Madelyn Rojo, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, the daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms, and contacted facility to complete a facility risk assessment. LPA ensured to apply hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to: 3 bedrooms and 1 bathroom for residents, common area, dining room, food supply, PPE supply, garage, outdoor area, and sheds. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Administrator completed the infection control domain and facility was found to be in substantial compliance at this time. No deficiencies are being cited. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Dec 22, 2021