Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Annual Continuation Visit and met with Administrator Zosima Rillera.

During visit, LPA toured 3 out of 3 resident bathrooms and observed each bathroom had working lights and available soap and paper towels. LPA measured the water temperatures in each bathroom and observed that they measured between 110 F - 118 F. LPA Marrufo reviewed the Centrally Stored Medication and Destruction Records (CSMDR) for residents R1-R6. Residents R2-R4 and R6 had medications that were not recorded in their CSMDRs.

LPA Marrufo reviewed the resident records for residents R1-R6. Resident R1's and R3's records were missing Consent Forms. R4's record was missing a Safeguard for Property and Valuables Form. R4's Physician's Report states R4 has dementia and the date of the exam on the most recent Physician's Report was 06/02/2021. R5's record was missing an LIC613 Personal Rights form. R5's Physician's Report states R5 has dementia and the date of R5's most recent exam was 06/19/2018. R6's record was missing a Safeguard for Property and Valuables Form, Consent Form, and LIC613 Personal Rights Form. R6's Physician's Report states R6 has dementia and the date of R6's last exam was on 08/08/2020.

LPA reviewed staff records for staff S1-S4. Staff S1 and S4 were missing LIC9052 Employee Rights forms.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. Advisory Notes were issued. See LIC9102 Advisory Notes for more information. This report was reviewed with Administrator Zosima Rillera and a copy of this report was provided.