Facility Evaluation Report

Licensing Program Analyst (LPA) Stephanie Cifuentes conducted an unannounced case management visit for deficiencies observed during investigation of complaint 11-AS-20220727140407 on 7/28/2022. LPA met with assistant administrator Catherine Espino and explained the purpose of today’s visit is to issue citations and was granted permission to enter the premises.

During tour of facility grounds LPA Cifuentes noted the following deficiencies:

1. At 10:20am LPA Cifuentes noted that Physician's Report for Resident 1(R1) is not signed by a physician.

2. At 10:18am LPA Cifuentes observed that R1 and R2 do not have TB tests.

3. At 11:18am LPA Cifuentes noted an assortment of empty boxes, boards and electrical parts around perimeter of facility. At 11:26am LPA noted that light in bathroom 2 is in disrepair and at 11:30am LPA observed pests in facility kitchen.

4. 11:33 LPA observed unlocked drawer in the kitchen were knives were stored and at 12:02pm LPA observed lock to closet were toxins are stored was not locked.

5. At 11:33am LPA Cifuentes observed knife in container on kitchen counter and at 11:38am, 11:46am, 11:50am and LPA Cifuentes observed toxins in both bathrooms and R1's room that were not in a locked area. 6. At 11:42 am and 11:44am LPA Cifuentes observed half-bed rails in bedrooms of R1, resident 2 (R2) and resident 3 (R3) and no physicians order was found in residents files.

7. At 11:56am LPA Cifuentes noted medication administration record was not marked for resident R3 from dates of 7/22/2022 until 7/28/2022.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citations issued (809-D)

An exit interview was conducted, and a copy of the report and Appeal Rights were provided to Staff Catherine Espino.