Most inspections found deficiencies related to environment and safety, such as lack of grab bars in bathrooms, unlocked scissors, and a staff bedroom located inside the kitchen, which posed immediate health and safety risks. Medication management was also a concern in an earlier report where prescribed medications were not administered as directed. The most recent inspection on September 13, 2024, identified several deficiencies including safety hazards and fingerprint clearance issues, resulting in civil penalties and required corrective plans. Some earlier reports showed no deficiencies, including the October 31, 2023 inspection, indicating some improvement before the latest findings. Several complaint investigations were not part of these reports, so no substantiated complaints were noted.
The visit was a required unannounced annual inspection to evaluate compliance with licensing regulations and assess facility conditions.
Findings
The inspection found deficiencies including lack of grab bars in two bathrooms, unlocked scissors in bathroom #1, and one staff member and one resident without fingerprint clearance. Civil penalties were assessed and plans of correction were required.
Severity Breakdown
Type A: 3
Deficiencies (3)
Description
Severity
Two out of three bathrooms did not have grab bars in showers, posing an immediate health and safety risk.
Type A
Unlocked scissors were observed in bathroom #1, posing an immediate health and safety risk.
Type A
One staff member and one resident did not have fingerprint clearance, posing an immediate health and safety risk.
Type A
Report Facts
Capacity: 6Census: 5Staff files reviewed: 4Client files reviewed: 4Fire/earthquake drill date: Aug 4, 2024Plan of Correction Due Date: Sep 14, 2024
Employees Mentioned
Name
Title
Context
Christian Gutierrez
Licensing Program Analyst
Conducted the annual inspection and authored the report
Tony Vasallo
Supervisor
Named in relation to findings and plans of correction
The visit was an unannounced subsequent visit to conclude the required Annual inspection of the facility.
Findings
No deficiencies were observed during the visit. The inspection included review of residents' medications, staff interviews, and attempted resident interviews.
Report Facts
Residents' medications reviewed: 4Staff interviewed: 2Residents attempted to interview: 5
Employees Mentioned
Name
Title
Context
Victoria Serna
House Manager
Met with Licensing Program Analyst during the inspection and participated in exit interview
The Licensing Program Analyst conducted an unannounced required annual inspection using the Compliance and Regulatory Enforcement (CARE) Tool to evaluate the facility.
Findings
The inspection found several deficiencies including a staff bedroom located inside the kitchen posing health and safety risks, non-operational sink faucet in bathroom #2, lack of hot water in bathroom #3, and incomplete personnel records for the facility administrator. The inspection was not fully completed due to time constraints, with some domains and interviews pending.
Deficiencies (4)
Description
Staff bedroom located inside the kitchen, posing an immediate health, safety or personal rights risk to persons in care.
Sink faucet in bathroom #2 is not operational, posing a potential health, safety or personal rights risk to persons in care.
Bathroom #3 sink faucet not delivering any hot water, posing a potential health, safety or personal rights risk to persons in care.
Facility administrator not maintaining a personnel file, posing a potential health, safety or personal rights risk to persons in care.
Report Facts
Capacity: 6Census: 4Plan of Correction Due Date: Oct 24, 2023Plan of Correction Due Date: Nov 3, 2023Plan of Correction Due Date: Nov 3, 2023
Employees Mentioned
Name
Title
Context
Victoria Serna
Care Manager
Met with Licensing Program Analyst during inspection and exit interview
Fernando Fierros
Supervisor
Named as supervisor on the report
Valeria Maldonado
Licensing Program Analyst
Conducted the inspection and authored the report
Toni C Santos
Administrator
Facility administrator noted as lacking a personnel file
An unannounced annual visit was conducted focusing on infection control, medication, and food review to ensure compliance with licensing requirements.
Findings
The facility was found to be operating within the scope of its license with adequate safety and hygiene measures. However, one deficiency was noted where medication was not administered as prescribed for one out of five residents reviewed.
Severity Breakdown
Type A: 1
Deficiencies (1)
Description
Severity
Medication was not given as prescribed for 1 out of 5 residents; specifically, medication capsules for Quetiapine Fumarate and Simvastatin were still in the medication bubble pack past the prescribed dates.
Type A
Report Facts
Residents medication reviewed: 5Staff files reviewed: 5Deficiencies cited: 1POC Due Date: Oct 29, 2022
Employees Mentioned
Name
Title
Context
Toni Santos
Administrator
Named in relation to administrator certificate and medication administration deficiency
Luis Mora
Licensing Evaluator
Conducted the inspection and signed the report
Wei Siew Ho
Supervisor
Supervisor overseeing the inspection
Victoria Serna
Care Manager
Met with Licensing Program Analyst during the inspection
An unannounced Annual Required / Infection Control Visit was conducted to evaluate the facility's compliance with regulations.
Findings
The facility was found to be in good repair with no observed deficiencies. Infection control practices were followed, including sanitizing stations, visitor logs, temperature checks, and use of PPE. No citations were issued.
Report Facts
PPE supply duration: 30Hot water temperature: 110Facility capacity: 6Resident census: 4
Employees Mentioned
Name
Title
Context
Toni Santos
Administrator
Met with Licensing Program Analyst during inspection and involved in facility tour and exit interview
Alma Gonzalez
Licensing Program Analyst
Conducted the unannounced annual inspection visit
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