Villa Alamar

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA was greeted by Yesenia Leon, LVN, Resident Services Director, Luciana Mitzkun Weston, Community Services Director, and Ingrid Estrella, Executive Associate Director. Administrator Mitch Leichter arrived later during the inspection. LPA explained the purpose of the visit. At the time of arrival, there were fourteen (14) various staff members and twenty-seven (27) residents in care. Entrance interview conducted. The facility is a one-story Residential Care Facility for the Elderly (RCFE) licensed for 43 non-ambulatory of which five (5) can be bedridden. The facility is home to residents with a dementia diagnosis. The facility has a hospice waiver for twenty (20) residents. Currently, there are eleven (11) residents on hospice and two bedridden residents. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings were checked. The facility was seen to be in good repair inside and outside. There are four fire extinguishers, inspection was current as of 6/24/2025. The carbon monoxide alarm and smoke alarms are hard wired and in good working order. Additionally, the facility has three pull fire alarms. Please continue to 809-C, Pg 2 The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. First aid kits were observed to be complete. Residents participate independently in holiday and birthday celebrations, pet therapy, art therapy, sensory activities, geographical tours via social media, live entertainment, local volunteer group participation, Cycling Without Age, local university and community college activities, physical exercise and activities, and outings to parks, restaurants, and other local attractions. The front entry consists of a sidewalk and concrete ramp entering the facility into the reception area. The facility consists of two wings and an additional building for resident occupancy adjacent from the main building. The main building is a horseshoe shaped building with approximately eighteen residents’ rooms. The adjacent building has seven resident rooms. There is a combination of residents’ rooms with shared bathrooms and residents’ rooms with private bathrooms in the main building and there are only shared bathrooms in the adjacent building. All bathrooms were inspected with secure grab bars and non-skid flooring. The back patio area consists of a garden patio with tables with umbrellas, chairs, and shady trees with a mural wall along the backside. The garden patio is conducive for outdoor visiting as well as various activities and celebrations. There are three dining areas and two common areas available to residents and visitors for dining, activities, and visiting with 24-hour access. The facility maintains a comfortable temperature. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs). During medication inventory, record review revealed on 2/17/2026 two medication errors occurred when Staff 1 (S1) did not provide Resident 1 (R1) two medications to self-administer, Quetiapine 50mg at 5:00 pm and Gabapentin 100 mg capsule 1 cap by mouth at bedtime (8:00 pm). Further record review revealed S1’s signature on R1’s Medication Administration Record (MAR) for those medications on 2/17/2026. Additionally, Please continue to 809-C, Pg 2. medication inventory record review revealed one bottle of Escitalopram for AM dosage was provided to the facility upon R1’s admission into the facility on 12/17/2025. Upon admission, the facility was provided one bottle of Escitalopram 10mg with a 90 count. During today’s medication inventory, there was an unexplainable shortage as Staff 2 (S2) counted 19 tablets in the bottle. S2 stated the medication was provided by R1’s responsible party at the time of R1’s admission and it was not known how many tablets were in the bottle at the time the medication was handed over to the facility staff. All persons associated with the facility have criminal record clearance. Administrator certificate is valid. Staff files reviewed had criminal record statements, health screenings, current first aid certificates, and all required training. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Feb 18, 2026

Allegation investigated: Facility staff are inappropriately restraining a resident.

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced 10-day complaint investigation based on the above stated allegation. LPA met with Yesenia Leon, Director of Residential Care and explained the purpose of the visit. Ingrid Estrella, Executive Associate was also present during the visit. During today’s visit, LPA obtained documents pertaining to the allegation, conducted interviews with staff, and conducted a tour of the facility. On the allegation, facility staff are inappropriately restraining residents, concern was brought to Community Care Licensing Division’s (CCLD’s) attention that residents are being improperly restrained. Interviews conducted revealed the facility has a “No Restraint” policy. Restraint training is provided to staff at the time of hire and an “Annual Restraint In-Service” is conducted annually, most recently in May 2025. Interviews conducted revealed staff are knowledgeable about the “no restraint” policy and adhere to the policy. Staff interviewed stated they have never witnessed a resident being improperly restrained and if they did, they would immediately let the staff know it is not allowed, per facility policy. Interviews conducted Please continue to 9099-C, Pg 2. Unsubstantiated revealed staff are aware the dining areas have limited space and stay observant of residents' movements to leave the table or come back to the table during mealtime. Record review revealed there is always staff presence in the dining areas at the time meals are being served. At approximately 11:40 am to 12:15 pm, LPA toured the facility including the facility’s three dining areas. LPA observed two staff members in each dining area with residents sitting at tables throughout each dining area. Based on observation, record review, and interviews conducted, the allegation that facility staff are inappropriately restraining residents is Unsubstantiated at this time. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Jul 9, 2025 · control 29-AS-20250701164159

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA was greeted by Yesenia Leon, LVN, Resident Services Director. LPA explained the purpose of the visit. At the time of arrival, there were nine (9) various staff members and twenty-six (26) residents in care. Entrance interview conducted. The facility is a one-story Residential Care Facility for the Elderly (RCFE) licensed for 43 non-ambulatory of which five (5) can be bedridden. The facility is home to residents with a dementia diagnosis. The facility has a hospice waiver for twenty (20) residents. Currently, there are twelve (12) residents on hospice and one bedridden resident. A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors, and floor coverings were checked. The facility was seen to be in good repair inside and outside. There are four fire extinguishers, inspection was current as of 6/27/2024. The carbon monoxide alarm and smoke alarms are hard wired and in good working order. Additionally, the facility has three pull fire alarms. The kitchen area was sufficiently stocked with two-day perishables and seven days of non-perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. First aid kits were observed to be complete. Residents participate independently in holiday and birthday celebrations, current event discussions, live entertainment, local volunteer group participation, Cycling Without Age, local university and community college activities, physical exercise and activities, and outings to parks, restaurants, and other local attractions. Please continue to 809-C, Pg 2. The front entry consists of a sidewalk and concrete ramp entering the facility into the reception area. The facility consists of two wings and an additional building for resident occupancy adjacent from the main building. The main building is a horseshoe shaped building with approximately eighteen residents’ rooms. The adjacent building has seven resident rooms. There is a combination of residents’ rooms with shared bathrooms and residents’ rooms with private bathrooms in the main building and there are only shared bathrooms in the adjacent building. All bathrooms were inspected with secure grab bars and non-skid flooring. The back patio area consists of a garden patio with tables with umbrellas, chairs, and shady trees with a mural wall along the backside. The garden patio is conducive for outdoor visiting as well as various activities and celebrations. There are three dining areas and two common areas available to residents and visitors for dining, activities, and visiting with 24-hour access. The facility maintains a comfortable temperature. Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Medication Administration Records (MARs). Medications are administered per Physician’s orders. All persons associated with the facility have criminal record clearance. Administrator certificate is valid. Staff files reviewed had criminal record statements, health screenings, current first aid certificates, and all required training. Exit interview conducted. No deficiencies noted. Copy of report issued at the time of the visit.the state’s words, verbatim · CDSS document, Feb 26, 2025

Allegation investigated: Illegal eviction. Facility staff did not provide proper notice for rate increase(s).

This is an amended report. On 04/05/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct a Subsequent Complaint Investigation Visit and Deliver Complaint Final Findings. LPA met with Community Services Director Luciana Mitzkun Weston, and explained the purpose of the visit. On the allegation: Illegal eviction. It is alleged that the facility sent an eviction notice by email providing only 15 days’ notice prior to the date of eviction/removal for Resident 1 (R1). It is alleged that the threat of eviction is related to payment issues. On 02/28/2024, LPA interviewed the Responsible Party for R1. Responsible Party (RP) indicated the facility has not called RP by telephone or emailed RP's current email address. According to RP, the facility only used RP's old email address for any correspondence related to R1, and they were upset that the facility sent an eviction notice to their old email address providing only 15 days’ notice. Continued on 9099-C Unsubstantiated This is an amended report. On 02/28/2024, LPA requested documents pertaining to the investigation, conducted observations of the pertinent areas of the facility, and interviewed both Residents and Staff members of the facility. LPA conducted an interview of Staff Member #1 (S1), who stated there was no eviction notice, or threat of eviction. S1 stated that R1 and their Responsible Party are consistently late with their rent, but the facility is just asking them to pay the amount on their monthly bill. LPA conducted record review of documentation pertinent to the allegation in the complaint. LPA received the following documentation: Facility Invoice Statements for Resident #1 (R1) with Payment Terms on 01/01/2024, 01/16/2024, 02/01/2024, 03/01/2024 that included current monetary balances and specified amounts for monthly rent and monthly received services by R1. LPA also received copies of email correspondence between the facility and the Reporting Party (RP) dated 12/28/2023 which informed RP that R1 was over two (2) months behind on rent and reminded RP to pay the rent on time in full. The 12/28/2023 email has no mention by the facility of eviction procedures for R1. Additionally, LPA received a hard copy of email correspondence between the facility and RP dated 02/14/2024 serving as a reminder to pay the outstanding rent to the facility. The 02/14/2024 email correspondence between the facility and RP had an attachment sent by the facility to RP consisting of a formal letter from the administrator of the facility. This formal letter was attached to the 02/14/2024 email from the facility to RP and was also sent by the facility to RP through Postal Mail, which has RP’s mailing address listed on the letter. The formal letter from the facility to RP indicated that R1 had an outstanding monetary balance at the facility of a total of $5,645.20 that was owed. The letter stated that the facility is conceding RP a one (1) month grace period to bring the account of R1 into good standing by making the full payment by 03/15/2024. The letter stated that if payment is not received by 03/15/2024, then the facility will begin to initiate eviction procedures according to regulatory guidance, but the letter did not state anything about current eviction procedures. On 03/05/2024, LPA asked RP if the mailing address the facility sent all documentation to about R1’s financial situation is a correct postal mailing address for RP. RP responded that at the time the documents were sent, it was a correct postal mailing address, but it was not checked that often at all. Continued on 9099-C This is an amended report. The letter did not indicate an eviction procedure had been initiated against R1, only that the facility will begin to initiate an eviction procedure on 03/15/2024 if RP continues with nonpayment of R1’s monthly bill and fails to make the full payment by that date. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. On the allegation: Facility staff did not provide proper notice for rate increase(s). It is alleged that the facility has new ownership, who recently increased the rates significantly without 60 days’ notice. The allegation states the rate increase is not due to a change in the level of care of the resident. On 02/28/2024, LPA requested documents pertaining to the investigation, conducted observations of the pertinent areas of the facility, and interviewed both Residents and Staff members of the facility. LPA conducted an interview with Staff Member #1 (S1), who stated that the facility sent all residents the payment invoice/bill for March 2024 on 02/21/2024. Due to an email error, two (2) residents received the wrong bill, meaning that the residents received the bill for each other. S1 stated this mistake/error in billing was due to the two (2) residents having almost identical surnames, and the invoices were initially sent to the incorrect residents. According to S1, the relatives of R1 immediately noticed the rate on the bill and thought that it was an increase in rates rather than an incorrect bill. S1 stated that they spoke with the relatives of R1 and provided a correct bill. On 02/28/2024, LPA interviewed R1’s Responsible Party (RP). RP admitted to LPA that there was an initial misunderstanding regarding a received invoice from the facility, as the facility had mistakenly sent RP an invoice for a separate resident that had an almost identical surname to R1. RP also had concerns about the facility invoices and believes that the facility has the wrong outstanding balance for R1. RP stated that the facility recently increased the rates significantly without 60 days’ notice. Continued on 9099-C This is an amended report. LPA conducted record review of documentation pertinent to the allegation in the complaint. LPA received the following documentation: Resident Rental Agreement Addendum for R1 that was signed/dated by the administrator of the facility on 10/20/2023. This Resident Rental Agreement Addendum was sent via postal mail to the address of RP and sent via email to the email address of RP that the facility had on file. The 10/20/2023 Rental Agreement Addendum stated that the facility would be increasing the rent for R1 beginning 01/01/2024 by eight (8) percent, which equaled a $125.40 increase in the monthly rate for R1. Therefore, the monthly rate for R1 went from $1,567.50 to $1,692.90. The facility maintained in the Rental Agreement Addendum that the increase in rent was necessary to maintain the caregivers/staff members of the facility due to wage demands and increased costs associated with operating the facility. The facility gave over 60 days’ written notice at the increase of rates, and was in compliance with regulation to increase resident rates. Based on the information obtained, there was insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time. Exit interview conducted, a copy of this report was provided to the facility. This is an amended report. This page is left intentionally blank.the state’s words, verbatim · CDSS document, Apr 5, 2024 · control 29-AS-20240226103842

Type of visit: Required - 1 Year

On 02/01/2024, Licensing Program Analyst (LPA) Brian Phillips arrived unannounced for an unscheduled visit to conduct a required Annual site inspection visit at the facility above. When the LPA arrived, they were greeted by Community Services Director Luciana Mitzkun Weston, as Administrator Mitch Leichter was physically unavailable, and informed them of the reason for the visit. The Administrator was informed of the visit via telephone by the Community Services Director upon the arrival of the LPA. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE), with an approved fire clearance capacity of Forty-Three (43) residents. The facility is approved for 43 non-ambulatory residents, of which five (5) may be bedridden, with an age range of residents sixty (60) years of age and older. The facility has an approved Hospice Waiver for twenty (20) residents. The physical plant of the facility consists of a semi separated building (2 indoor areas) connected by an outdoor courtyard. The two (2) buildings are separately labeled by the facility as the "Main" building and the "Casa" building. The Main building consists of resident bedrooms, restrooms, shower areas, a Centrally Stored Medication room, nursing station room, two (2) dining room, kitchen, activity room, storage area closets/rooms, and a beauty salon, Staff offices, and a central lobby administrative area upon entry into the facility. The Casa building consists of resident bedrooms, nursing station room, shower area, dining room, Lounge room, restrooms, and storage closets/rooms. The outdoor courtyard between the buildings of the facility contains a locked indoor service area which is the designated laundry room area of the facility. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations and an outdoor patio/courtyard area with furniture and shade. KITCHEN: The facility maintains one (1) main kitchen room/area for both the Main building and the Casa building of the facility. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to residents. Kitchen appliances were in operable condition and looked clean/in good repair. Continued on 809-C The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last over a week (7 days). Additional perishable food items were maintained in a storage area in a locked cabinet in the kitchen area of the facility as well as an extra refrigerator and extra freezer located in a locked room/addendum off of the hallway of the facility. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation between 105-120 degrees Fahrenheit. Items that could constitute a danger to residents are kept inaccessible to residents in the kitchen area. The kitchen was clean and sanitary, with covered trashcans and operating ventilation systems. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. There is enough tableware and utensils for all residents living in the facility, and enough equipment for the storage, preparation, and service of food. COMMON AREAS: The indoor areas of the facility consist of semi separated building(s) (2 indoor areas) connected by an outdoor courtyard. The two (2) buildings are separately labeled by the facility as the "Main" building and the "Casa" building. The Main building consists of resident bedrooms, restrooms, shower areas, a Centrally Stored Medication room, nursing station room, two (2) dining room, kitchen, activity room, storage area closets/rooms, and a beauty salon, Staff offices, and a central lobby administrative area upon entry into the facility. The Casa building consists of resident bedrooms, nursing station room, shower area, dining room, Lounge room, restrooms, and storage closets/rooms. At the time of the visit, the common areas of the facility were observed to be appropriately furnished, with all furniture in good condition. There are no fireplaces in the facility, therefore no need to be inaccessible to residents. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector(s) were operational at the time of the visit. The facility has multiple fire extinguishers that were fully charged and serviced annually, all being tagged as serviced in 2023. This facility contains multiple dining rooms, a Lounge, Staff offices, a beauty salon/barber, nursing stations, five (5) resident restrooms, three (3) resident shower/bathing rooms, living room area, kitchen area, dining room, laundry room, twenty-five (25) resident bedrooms (both individual and shared), a locked centrally stored medication containment area, extra storage areas for additional perishable food, closets/rooms in the hallways of the facility containing extra linen/bedsheets/pillows, and storage areas for resident personal hygiene equipment constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. Continued on 809-C There are activity supplies and equipment, including activity materials for the residents such as television, puzzles, games, etc. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for resident use. The laundry area for the facility is located in a locked addendum/room area off of the outdoor courtyard of the facility that is inaccessible to residents. There is a main entrance walkway into the facility and an administrative entrance area for visitors. There is an electronic combination lock between the administrative entrance lobby area of the facility and the main interior. The facility has electronic auditory systems on all doors that can exit the interior of the facility, with a loud noise when a door exiting the facility is opened. The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature. Hallways, bedroom doors, and walls are in good repair. OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility is well maintained and consists of cement walkways and grass areas. The facility outdoor courtyard between the Main indoor building and the Casa indoor building is well maintained and is paved with a walkway between the facility. The backyard is conducive for outdoor visitation. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The exterior of the facility has a closed perimeter which consists of a wall around the entire facility with latched gates. Inside of the perimeter is the outdoor/outside activity area for residents with a patio in the backyard, furniture, shade, and sheds that are locked and contain outdoor maintenance materials for the facility. LPA was shown the inside of all sheds upon request. There is also a second story to the Casa building of the facility that consists of a Staff member break room and a Staff member private kitchen along with Staff offices. This area is locked and inaccessible to residents. The facility has an outdoor activity area that is provided with a shaded area and furnished for outdoor use. There are no bodies of water noted on the facility property. The designated laundry area is a locked room in the back of the facility, and there is another locked storage area where cleaning products are stored, which are kept locked and inaccessible to residents. The laundry room is always locked and accessible through the back door of the Main building of the facility, next to another locked area which has all emergency items locked with electronic combination locks. Staff members are the only individuals allowed to do laundry and the entire room is kept locked at all times. There was emergency food and water in a storage area in the back of the facility and in the extra perishable food storage area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. Continued on 809-C There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. LPA did not observe any noticeable outdoor hazards in areas accessible to residents. BEDROOMS: The facility has twenty-five (25) resident bedrooms, both individual bedrooms for one (1) resident and shared bedrooms for two (2) residents. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The bedrooms have storage areas for clean linens, towels, pillows, etc. Each resident’s bedroom has a single bed or beds, nightstand, and lights/nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. All resident bedrooms in the Casa building of the facility contain their own private restroom within the bedroom area. All resident bedrooms contain monitored signal/auditory/call system in place by the facility that alerts Staff when a resident needs assistance. RESTROOMS: There are five (5) resident restrooms and three (3) resident shower/bathing rooms in the facility. The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms/showers inspected had assistive equipment for residents including grab bars and/or non-skid surfaces. The restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per the regulations between 105-120 degrees Fahrenheit. Nightlights are installed in the hallways outside of the resident restrooms. The facility maintains private, personal restrooms for residents in each resident bedroom of the Casa building. The Main building has communal restrooms for residents in the hallways. All resident restrooms consist of a sink and toilet with soap, paper towels, and additional supplies, while the resident shower/bathing areas consist of a shower and/or bathing area with assistive equipment such as grab bars and non-skid surfaces. Continued on 809-C RECORDS: The facility keeps confidential storage of both resident and Staff member records on-site at the facility. Staff member records were reviewed for, but not limited to Health Screening Report/Tuberculosis (TB) Clearance for facility personnel, Personnel Record (employment application), verification of age over 18 years old, education, and experience, approved Certification for the Administrator, verification of first aid training, Criminal Record Statement, Continued on 809-C Criminal Record Clearance/Exemption, Verification of Staff training, Employee Rights, and Abuse Reporting Requirements. All staff members’ personnel records reviewed by LPA had the appropriate documentation. The administrator of the facility has an active Residential Care Facility for the Elderly (RCFE) Administrator Certificate with an effective date of 02/21/2023, and an expiration date of 02/20/2025. Resident records were reviewed for, but not limited to Pre-Admission/Placement appraisals, Resident Appraisals, Appraisal Needs and Services Plan (ANS), Physicians’ Report for RCFE, Identification and Emergency Information, Current Admission Agreement with signatures, Personal Rights for Residents, Record of Residents safeguarded cash resources, Record of Resident personal property/valuables, Physician Orders for Life Sustaining Treatment (POLST), Responsible Person or Conservator of Resident, Self-management of medications if applicable, Medication Orders, and Medication Logs. The facility also keeps records of resident vital signs and a resident weight record for all resident files reviewed. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information. MEDICATIONS: The facility maintains a locked centralized storage area for resident medications in each building. Centrally Stored Medications are in a locked storage containment area within the medication room of the facility, which is located in the Main building of the facility. Centrally stored medications for the Casa building are stored in the Nursing Office/Room which is also locked and inaccessible to residents. In both instances, the medications are stored within a locked cabinet/cart that remains locked within those areas, inaccessible to residents. The medication rooms remain locked at all times, inaccessible/locked to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record, The Medication Administration Record, and the record of Controlled Medications. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. 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. The facility’s policies and procedures as it pertains to infection control are adequate. Continued on 809-C FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility keeps posted copies of facility documentation such as the RCFE License Certificate, LIC 500 Personnel Report, Documentation of Facility Waivers, Plan of Operation, Emergency Disaster Plan for Residential Care Facilities for the Elderly (RCFE), Facility Infection Control Plan/Mitigation Plan, Certificate of Liability Insurance, Valid Administrator Certificate, and a Facility Sketch. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process. A deficiency was cited . Exit interview conducted. A copy of the report was issued to the facility. A Type A deficiency was cited for California Code of Regulations (CCR) 87355(e)(2) Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c). The Licensee did not ensure that one (1) Staff member was associated to the facility prior to working in the facility, which poses an immediate safety risk to persons in care. Exit Interview Conducted. Copy of the Report provided to the Facility.the state’s words, verbatim · CDSS document, Feb 1, 2024