The Retreat at Greenhurst

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a health and safety check on the residents residing in the facility on 10/12/23 at 2:00pm. LPA met with Caregiver Carlotta Batul and stated the purpose of the visit. Administrator certificate for Antonette Tin expires 7/5/24. The facility is licensed to serve 6 non-ambulatory of which 1 maybe bedridden. Hospice waiver approved for 4 residents to be able to receive hospice care services. There is 0 residents receiving hospice care services at this time. LPA observed residents resting and preparing for dinner during this visit. Dinner will consist of chicken adobo, potatoes, steamed vegetables with strawberries and jello for dessert and choice of drink. LPA observed fire extinguisher, smoke alarm, carbon monoxide detector in the home. LPA observed 2 day perishable and 7 days of non-perishables during this visit. During LPA visit the temperature inside the facility measured to be at 69 *F which is within the required range of 68-85*F. The water temperature measured at 115.0*F which is within the required range of 105-120*F. LPA observed caregiver(s) performing other duties during this visit. LPA did not observe any health and safety hazards during this visit. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, Oct 12, 2023

Allegation investigated: Staff did not seek medical attention to resident in care.

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to investigate the above mentioned allegation on 8/28/23 at 9:30am. LPA met with Antonette Tin and stated the purpose of the visit. LPA conducted interviews during this visit of staff and resident #1 (R1). Regarding allegation, "Staff did not seek medical attention to resident in care." LPA conducted interviews which revealed that Administrator Antonette Tin did not seek medical attention upon the request of R1's Licensed Skilled Professional. Administrator stated that she was reiterating how a lack of medication could affect R1's behavior based on R1's past history and responsible party information. Based on interviews and the admittance from the Administrator that she did not seek medical attention for R1 because R1 was not having behaviors. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 28, 2023 · control 27-AS-20230825095012

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Aug 29, 2023

Incidental Medical and Dental Care The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on Administrator admittance confirming she did not seek medical attention as requested for R1. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 28, 2023

Plan of correction: Licensee/Administrator shall submit in writing that any medical attention upon request or any other circumstance that threatens the safety of the residents will be handled according to Title 22 regulations at all times. Please fax the POC by 8/29/23.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 8/18/23 at 9:15am to follow up on complaint 27-AS-20230518153045. LPA met with Carlotta Batul, Caregiver and stated the purpose of the visit. Upon further review of interviews and documentation, LPA observed evidence to cite deficiencies during this visit. Administrator Antonette Tin arrived not to assist with todays visit but to deliver groceries and left. During the visit on 8/16/23, LPA interviewed the administrator and staff #1 regarding the medication administration process. Both stated to LPA that there is never use of a 7-day pill box for residents. LPA obtained photos that were taken approximately 4/25/23 and 5/3/23 in which 7-day pill boxes were observed containing medications with residents’ names taped to them. LPA observed pills in the pill boxes for at least Sunday and Monday, as well as S1 in the photo dispersing the pills without gloves. In addition, the photos show that the medications were accessible to residents. LPA observed the validity of the photos, as the furniture the medications were on, is still being used inside the facility. LPA inquired with Caregiver Jan Jimenez who stated the photo looks like Carlotta Batul. Carlotta Batul confirmed she is in the photo preparing the medication. These photos demonstrate that the LPA received false statements from the Administrator and S1 regarding the use of the 7-day pill boxes during medication management. In reviewing the Infection Control Plan that was submitted to Community care Licensing on 6/29/22 from the Administrator, LPA observed on page 5 of 6, the plan states “(F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance”. Based on observations and the review of documentation submitted, the preponderance of evidence standards has been met. 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. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 18, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Aug 19, 2023

Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored:Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: Based on photo that shows medications were transferred from original container to a 7-day pill box. Staff are not storing medications in original containers. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2023

Plan of correction: Licensee will submit a statement of understanding this section of Title 22 Regulations by POC due date of 8/20/23 and submit via fax staff in-service training by the POC date of 8/25/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Aug 19, 2023

Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: 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. This requirement was not met as evidenced by: Based on photo that shows medications were on a table in the common area. Medications are not kept locked and inaccessible to residents in care. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2023

Plan of correction: Licensee will submit a statement of understanding this section of Title 22 Regulations by POC due date of 8/20/23 and submit via fax staff in-service training by the POC date of 8/25/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(1)(C) · Plan of correction due date: Aug 19, 2023

Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: Medications shall be centrally stored under the following circumstances:Because of potential dangers…condition or the habits of other persons in the facility, the medications are determined by…Department to be a safety hazard to others. This requirement was not met as evidenced by: Based on photo shows staff transferring medications without gloves. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2023

Plan of correction: Licensee will submit a statement of understanding this section of Title 22 Regulations faxed by POC due date of 8/20/23 and submit via fax staff infection control training by the POC date of 8/25/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87207 · Plan of correction due date: Aug 19, 2023

False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Based on Administrator and S1 both stated that 7-day pill boxes were not used in the facility. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2023

Plan of correction: Licensee will submit a statement of understanding this section of Title 22 Regulations faxed by POC due date of 8/20/23 and submit via fax staff mandated reporter in-service training by the POC date of 8/25/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(d)(6) · Plan of correction due date: Aug 19, 2023

Infection Control Requirements …licensee shall develop an Emergency Infection Control Plan that includes infection control measures that are not already addressed in the Infection Control Plan…updated as necessary or whenever new infection control measures are recommended… as determined by the Department...updates…shall be made available to staff, residents and if applicable, each resident’s representative, and submitted to the Department. This requirement was not met as evidenced by: Based on a review of Infection Control Plan that indicates staff will have knowledge and skill of infection control evidenced by safe job performance. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2023

Plan of correction: Licensee will submit a statement of understanding this section of Title 22 Regulations by POC due date of 8/20/23 and submit via fax an updated infection control plan by the POC date of 8/25/23.

Allegation investigated: Staff are not providing residents food of quality and in the quantity necessary to meet the needs of the residents

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 8/16/23 at 10:45am to conclude the investigation of the above mentioned allegations. LPA met with the Administrator Antonette Tin regarding the purpose of todays visit. LPA conducted interviews of staff and Administrator during this visit. Regarding allegation, Staff are not providing residents food of quality and in the quantity necessary to meet the needs of the residents, LPA observed that the facility was utilizing menus that were posted but not notifying residents and/or responsible parties of any changes. In addition, during interviews, LPA obtained information that the residents were receiving sandwiches on a more than usual basis. Since LPAs visit on 5/20/23, the menus have been revised and notations of any changes or alternatives are being made. LPA received notification through interviews that the meals are of better quality and quantity now. Substantiated Based on interviews the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D during this visit. If any 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 with Caregiver Carlotta Batul, whom Antonette TIn requested to sign todays report, and a copy of this report was provided. Regarding allegation, Medications are not kept locked and inaccessible to residents in care, LPA observed that medications were locked and inaccessible to residents during unannounced visits conducted on 5/20/23, 7/5/23, 8/4/23, and 8/16/23. Licensing Program Analyst did not observe a preponderance of evidence. The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted with Caregiver Carlotta Batul, whom Antonette TIn requested to sign todays report, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 16, 2023 · control 27-AS-20230518153045

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(1) · Plan of correction due date: Aug 16, 2023

Personnel Requirements - General All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:Principles of good nutrition, good food preparation and storage, and menu planning. This requirement is not met as evidenced by: Based on interviews it was confirmed that menus were not updated and sandwiches were served more times than residents wanted for dinner. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 16, 2023

Plan of correction: Licensee shall ensure that staff are adhering to the food training and documenting changes and/or alternatives provided to residents. POC cleared prior to todays visit.

Allegation investigated: Licensee did not issue refund in a timely manner

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to open the initial 10 day for the complaint. LPA met with Caregiver, Natividad Rebuyon and stated the purpose of the visit. The caregiver contacted the Administrator regarding todays visit. The Administrator Antonette Tin stated that she is unable to attend todays visit and the residents file is locked and staff do not have the key. The Administrator also stated that the refund due to resident in the amount of $6000.00 has not been sent. Administrator stated the check will be sent today through certified mail. LPA was unable to review residents file during this visit. Based on admittance from Administrator, that the refund has not been sent yet. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 4, 2023 · control 27-AS-20230802153231

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Aug 7, 2023

Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees...within 15 days after the personal property is removed. This requirement is not met as evidenced by: Based on Administrator admittance confirming the refund has not been issued to the individual responsible for paying residents fees. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2023

Plan of correction: Licensee stated that the refund in the amount of $6000.00 will be sent via certified mail today, 8/4/23 to individuals address on file. Proof of such mailing shall be faxed to CCL by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Victoria Brown arrived on a subsequent visit and observed deficiencies. LPA met with Natividad Rebuyon, Caregiver and stated the purpose of the visit. LPA requested to see the files of all the residents specifically their Admission Agreements. The caregiver provided medication documents. LPA spoke with the Administrator who stated the staff do not have the key and she is unavailable to assist with todays visit. Due to confirmation through observation, Community Care Licensing was unable to review files for residents during this visit. The preponderance of evidence standard has been met. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Aug 7, 2023

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on Administrator admittance confirming the staff do not have access to resident records during this visit. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2023

Plan of correction: Administrator shall state in writing that the resident records shall be made readily available for review by the licensing agency. This POC shall be faxed to CCL by POC due date.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Victoria Brown arrived on a subsequent visit. LPA met with Natividad Rebuyon, Caregiver and stated the purpose of the visit. This visit is to ensure the health and safety of the residents residing in the home. Administrator Certificate expires 7/5/2024. Upon arrival LPA observed 1 resident sitting at the table watching television while having lunch. 3 residents were sleeping during this visit. LPA observed the (RCFE) Complaint Poster (PUB 475) is not in compliance with the regulations which shall be 20" x 26" in size and posted in the main entryway of the facility. The facility is licensed for a capacity of 6 non-ambulatory of which 1 maybe bedridden. 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 76*F which is within the required range of 68-85*F. The hot water temperature was measured at 111.2*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. Facility has a hospice waiver for 4 of which there is 1 residents receiving hospice services at this time. 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. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. A copy of their rights was provided (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 4, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(c)(2)(A) · Plan of correction due date: Aug 7, 2023

Personal Rights Licensees shall prominently post...the Elderly (RCFE) Complaint Poster (PUB 475)...shall be 20" x 26" in size and be posted in the main entryway of the facility. This requirement is not met as evidenced by: Based on LPA observation during a tour of the facility during this visit. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 4, 2023

Plan of correction: Administrator shall submit proof of the poster posted in the facility by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 7/5/23 at 12:30PM. Administrator Certificate expires 7/5/2024. LPA met with Carlota Batul, Caregiver and stated the purpose of todays visit. Administrator Antonette Tin arrived within 15 minutes. The facility is licensed for a capacity of 6 non-ambulatory of which 1 maybe bedridden. 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 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 109.3*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. Facility has a hospice waiver for 4 of which there are 2 residents receiving hospice services at this time. 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. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Facility Responsibility (LIC308) Liability Insurance Personnel Report (LIC500) Administrator Certificate-Updated Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, Jul 5, 2023

Allegation investigated: Staff are not providing adequate food service to residents Staff are not providing paper towels in restroom

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude the investigation of the above-mentioned allegations on 2/23/23 at 11:00AM. LPA met with Gloria Alejo, Caregiver and stated the purpose of the visit. LPA reviewed interviews of Responsible Parties of resident #1 (R1) – (R7) and Staff #1 (S1) – (S-7) and Administrator, Admission Agreement, Pre-assessment form for R1, facility notes, and home health notes for R2. Regarding allegation “Staff are not providing adequate food service to residents” LPA found that the food service is not consistent with the menu and does not include periodic changes. Through interviews LPA found that residents are receiving soup and sandwiches routinely for dinner and snacks are not being provided after thier 4pm dinner. Allegation SUBSTANTIATED Substantiated Regarding allegation, “Staff are mismanaging residents’ medication” LPA found that R1 did not have any documented stored medications at the facility during the respite care. There was no sufficient evidence that R1 received another resident’s medication on a breakfast tray. Allegation UNSUBSTANTIATED Regarding allegation “Staff made inappropriate comments towards resident” LPA found that there was not a preponderance of evidence that suggests staff was speaking inappropriately to residents. This was based on interviews conducted with staff and residents and their responsible parties. Allegation UNSUBSTANTIATED Regarding allegation “Staff are not responding to residents call bell in a timely manner” LPA found there was not a preponderance of evidence that suggest the staff are not responding to residents in a timely manner. Allegation UNSUBSTANTIATED Regarding allegation “Staff threatened resident with eviction” LPA obtained a copy of the note provided to the Administrator stating R1 was relocating on 11/7/22. The Responsible Party was unable to be reached for an interview and all other interviews concur that they have not received an eviction notice verbal nor in writing. Allegation UNSUBSTANTIATED Licensing Program Analyst did not observe a preponderance of evidence. The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, and a copy of this report was provided. Regarding allegation "Staff are not meeting residents hygiene needs" Through interviews LPA did not obtain a preponderance of evidence that residents hygiene needs are not being met. Through interviews staff, residents and residents responsible parties concur that the hygiene needs are being met. Allegation UNFOUNDED The preponderance of evidence standards has not been met. “This agency has investigated the complaint alleging, the above-mentioned allegation(s). We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.” Per the California Code of Regulations, Title 22, Div 6, Ch 8, no violations cited during this visit. Exit interview conducted copy given. Regarding allegation “Staff are not providing paper towels in restroom” LPA found that through interviews the paper towels were not kept in the bathroom(s). During LPA visit the paper towels were placed in the bathroom. Allegation SUBSTANTIATED Based on interviews the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 9099D during this visit. If any 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, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 23, 2023 · control 27-AS-20221118145005

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(3)(5) · Plan of correction due date: Mar 9, 2023

General Food Service Requirements Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. This requirement is not met as evidenced by: Licensee having the same type meal for dinner on a daily basis and snacks not offered from 4pm until breakfast at 7:30am. Based on interviews it was confirmed that dinner is always the same and snacks are not offered. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2023

Plan of correction: Administrator shall create a menu based on the regulation standards and submit by fax a revised menu to include other menu options with snacks for residents by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3) · Plan of correction due date: Mar 9, 2023

Personal Accommodations and Services Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident... This requirement is not met as evidenced by: Licensee did not make available paper towels for residents or visitors Based on observation staff placed paper towels in bathrooms during CCL visit. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 23, 2023

Plan of correction: Administrator shall ensure all toiletries are accessible for use on a daily basis. A letter of understanding shall be submitted by fax by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 5/20/22 at 2:20PM. Administrator Certificate expires 7/5/2022. LPA met with Jeanne Bayan, Caregiver and stated the purpose of todays visit. Administrator Antonette Tin arrived within 5 minutes. The facility is licensed for a capacity of 6 non-ambulatory of which 4 may be bedridden. 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 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 109.7*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. Facility has a hospice waiver for 4 of which there are 0 residents receiving hospice services at this time. 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. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Facility Responsibility (LIC308) Liability Insurance Personnel Report (LIC500) Administrator Certificate-Updated Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, May 20, 2022