Marina's Home

Type of visit: Required - 1 Year

On September 3, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Ermenia Domingo and explained the purpose of today's visit. Caregiver, Gary Baldoza arrived during the inspection. LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. This is a 6 bed facility with 2 private rooms, 2 shared rooms and 2.5 bathrooms. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. LPA observed chemicals underneath the kitchen sink was not locked and accessible to residents in care. Central storage for medication was observed to be locked and inaccessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 107-110 degrees Fahrenheit. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. A review of (5) resident files was conducted and noted on the LIC 858. A review of (2) staff files was conducted and noted on the LIC 859. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. . This report is reviewed and discussed with the caregiver. A copy of this report and the appeal rights were providedthe state’s words, verbatim · CDSS document, Sep 3, 2024

Type of visit: Required - 1 Year

REPORT AMENDED TO RESCIND DEFICIENCY AND CIVIL PENALTY. LPA met with Gary Baldoza during this visit. Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/8/23 at 10:00AM. LPA met with Caregivers Ermenia Pascual Domingo and Andres De La Cruz Bayang who contacted the Administrator Marina Baldoza regarding the purpose of todays visit. Marina Baldoza arrived at 12:00pm to assist with todays visit. The Administrator Certificate was observed for Marina Baldoza which expires 8/16/24. LPA observed a receipt that indicates on 9/28/23, the Licensing fees were paid in the amount of $495.00. The facility is licensed for a capacity of 6 non-ambulatory residents of which 2 may receive hospice care services. There are 0 residents receiving hospice services at this time. LPA was provided a copy of the approved, signed, hospice waiver for 2 during this visit. LPA observed residents and conversed with them during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 117.1*F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed 3 staff and 2 resident files and conducted interviews during this visit. LPA did not observe a first aid/CPR certificate for the 3 staff during this visit. LPA observed the following that shall be cited during this visit. LPA observed that the 2 caregivers are not associated to the facility on LIS system nor the Guardian system during this visit. Administrator provided a copy of a roster with the 2 staff hand written dated 7/12/23, however, there is no proof that the document was submitted to Community Care Licensing (CCL) and administrator did not follow-up to ensure the staff were associated to the facility. Administrator was provided a copy of the guardian roster as well that did not contain the 2 staff names. DEFICIENCY AND CIVIL PENALTY RESCINDED. PROOF WAS PROVIDED THAT CAREGIVERS WERE INADVERTENTLY REMOVED BY COMMUNITY CARE LICENSING (CCL) SYSTEM. LPA OBSERVED A LIS ROSTER DATED 5/29/2020 THAT INCLUDES BOTH CAREGIVER NAMES THAT LICENSEE DID NOT REQUEST TO BE REMOVED. Upon a file review the following items were discussed to be submitted with any changes annually: LPA and Administrator reviewed the Infection Control Plan which is to be completed and submitted to Community Care Licensing (CCL), Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610E), Plan for incidental and Medical and Dental Care, Liability Insurance, Control of Property, Health Screening with TB for all staff. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. You are hereby assessed an immediate civil penalty is being assessed in the amount of $200 during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.the state’s words, verbatim · CDSS document, Oct 8, 2023

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Oct 9, 2023

Personnel Requirements - General Deficiency and Civil Penalty RESCINDEDthe state’s words, verbatim · CDSS document, Oct 8, 2023

Plan of correction: Deficiency and Civil Penalty RESCINDED

From the deficiency page — Deficiency type: Type A · Plan of correction due date: Oct 9, 2023

Personnel Requirements - General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69... Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: LPA did not observe first aid/CPR certificates for that caregivers 1 & 2 nor the Administrator. Based on: LPA observed expired certificates during file review. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 8, 2023

Plan of correction: Training scheduled for 10/16/2023 for 4 staff. Plan of Correction cleared during todays visit.