Baldwin Gracious Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Maria Lerma. The purpose of the visit was discussed telephonically with Administrator Herminia Pegolla telephonically. There are currently 5 elderly residents with Dementia 60 years and older residing in the facility. Zero (0) residents are enrolled in hospice or home health at this time. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in log. The facility submitted a COVID-19 Mitigation Plan and Infection Control Plan. Operational Requirements: A current Plan of Operation and Personnel files were reviewed. The facility has a Dementia Waiver in place. A Hospice Waiver for 6 is approved. A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room 2. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expired 7/1/2023. However, other parts of coverage are current. A surety bond is not applicable. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed for six (6) non- ambulatory residents, of which 1 may be bedridden. It consists of a kitchen, living room, dining room, activity room, covered patio area, backyard, laundry room, 3 resident bedrooms, 1 staff room, 2 bathrooms, and detached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances were observed unlocked in the laundry room. The laundry room was not locked. Kitchen knives were unlocked in cabinet and drawers. Citations were issued. The main entrance door auditory alarm was turned off and side door's auditory alarm is not operable. The facility has three (3) fully charged fire extinguisher. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Staffing: A total of 3 regular caregiver staff & 4 on-call staff provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificates expires 10/16/2023. Personnel files/training were reviewed; with the exception of on-call staff (S2's) file. Staff (S5) does not have a file, but is cleared and associated. Citation was issued. Resident Records/Incident Reports: A total of five (5) resident files were reviewed; which included admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information. Resident (R5) did not have a current Physician Report. RCFE complaint poster and Personal rights were observed posted. ***narrative continues next page*** Resident Records/Incident Reports: A total of five (5) resident files were reviewed. Files were observed to be incomplete. They were missing admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information. RCFE complaint poster and Personal rights were observed posted in the facility entrance area. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. No Physician orders for modified diets are on file. Sanitation practices and kitchen cleanliness was observed. Incident Medical and Dental: Three (3) centrally stored resident medications were reviewed; containing 30-day supply of medications. Resident (R1) had medications in their room drawer that were unlocked. Medical and dental transportation is provided by family members and staff. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. The last emergency disaster drill was completed on 3/6/2023. See next page Residents with Special Health Needs: No residents are receiving home health or hospice services. Postural support physician orders are on file. Half rails for mobility assistance were observed in some resident beds. Individual Service Plans and Appraisals were observed in resident files. No residents have prohibited health conditions. NOTE: Change of Administrator is pending. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with staff Maria Lerma. A copy of the report and appeal rights were issued.the state’s words, verbatim · CDSS document, Jun 23, 2023

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Nune Margaryan conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Assistant Administrator Jose Bongay and explained the reason for the visit. Physical Plant was toured, residents files and medication records were reviewed, staffs files records reviewed and food supply was inspected. The facility is licensed for six (6) residents over the age of 60, with a hospice waiver for two (6). The facility is a single story structure located in a residential neighborhood. It consists of the following: (3) resident bedrooms, (1) staff bedroom, (1) resident bathroom, (1) staff bathroom, kitchen, dining room, living room, laundry room, detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. LPA and Assistant Administrator toured the facility. All indoor and outdoor passageways were free of obstruction. There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask during this visit. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods. Sharps, cleaning supplies are locked and inaccessible to residents. Smoke / Carbon monoxide detectors were in compliance and operational. There are (3) fire extinguisher located throughout the facility which are fully charged. The common areas (dining room, living room) appeared to be clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings. Medications are centrally stored in a locked cabinet in the kitchen. Continue 809C The bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested and maintained within the required range of 105-120*F. LPA observed the centrally stored medication area to be locked and inaccessible to residents. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. LPA reviewed residents files to confirm emergency contact is updated. Residents medications reviewed. Medications documented properly and stored appropriately. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared. LPA provided a Technical Assistance LIC 9102 regarding N95 Fit testing for staff. Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview was conducted with Assistant Administrator Jose Bongay and a copy of this report and LIC 9102 was provided. .the state’s words, verbatim · CDSS document, Jun 24, 2022

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Facility Manager Hermie Pegollo and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected. The following was observed/inspected: LPA and Facility Manager toured the home and inspected (3) resident bedrooms, (1) staff bedroom, (1) resident bathroom, (1) staff bathroom, kitchen, dining room, living room, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and measured at 66.3F which is below the required 105F - 120F degrees. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. Carbon Monoxide detectors are intertwined with the smoke detectors and were operable. There are (3) fire extinguisher located throughout the facility which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Cleaning supplies and toxins are locked under the sink and are inaccessible to residents. First Aid kits were fully stocked with current manual. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed. (4) out of the (4) resident medications were reviewed. Medications are centrally stored in a cabinet in the kitchen. Medications are documented properly and given as prescribed. Staff and Resident files were not reviewed during today's visit. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 19, 2021