Facility Evaluation Report

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to continue the Annual Required 1 Year inspection and met with staff, Charity Butler(S2). Administrator, Mantu Sandhu arrived a few minutes later. This facility is licensed for 30 nonambulatory residents, of which 4 may be bedridden in rooms 6 and 7 only. The facility also has an approved Hospice Waiver for 10 of the 30 residents to receive hospice services. LPA previously started the 1-year inspection on 7/27/2023.

During todays inspection, LPA toured the entire inside and outside of the facility, with S2 and found 2 bedroom alarm doors and the staff room auditory door turned off and not operational during inspection. This facility has several wings and residents require an auditory alert system that is operational to alert and communicate with staff if assistance is needed. On today's inspection residents S6 pendant button was pushed and LPA waited 21 minutes and then alerted staff that no one had responded to the call button. During today's inspection the fire extinguisher was observed last serviced on 6/15/2022 and did not meet the required yearly servicing on time. LPA also went over the kitchen needing deep cleaning top to bottom and refrigerators as they all showed stuck on food, dirt, grime.

LPA is unable to complete inspection today and will return at a later date to go over the rest of the resident, staff files, facility files. LPA will also return to issue citations warranted, civil penalties for repeated citations within a 12-month period for LPAs observation today 9/22/23 and on July 27, 2023.

During todays inspection LPA found staff S7 who was recently working and was not associated to the facility as required and no proof of any training in file. All documents in the file were blank. A civil penalty for $100.00 is being assessed today for S7 not being associated to this facility

The following deficiencies were observed (see LIC 809-C) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.