Princess Lodge

On February 13, 2025, at 12:45 PM, Licensing Program Analysts (LPA), Kenneth Madrigal and Manuel Monter, conducted an unannounced Required 1 - Year Visit. LPAs stated the purpose of the inspection visit and met with Staff 1 (S1) who contacted Olivia Velasquez, Administrator Designee (AD) and was granted entry to the facility. Olivia stated that “Judith Morales, the Administrator (ADM) is out of the country.” LPAs called Judith Morales on the phone, but ADM did not pick up the phone, so LPAs left a voicemail. AD stated there are 7 facility staff, and 17 residents present at the time of the visit. The facility has 16 resident rooms, 8 resident bathrooms, one dining room, two living rooms, one office, one kitchen area, one laundry area, one storage area, and 98 sprinklers. During today's visit, the LPAs toured the facility inside and out with AD. In the kitchen area, all the sharps and chemicals are locked and inaccessible to residents in care. In the kitchen area, a portion of the wall above the faucet and below the glass wood cabinet has exposed drywall. The facility room temperature is 75 degrees Fahrenheit. In the hallway leading to the storage room and perpendicular to the laundry room, there is a water leakage. (Photographs were taken.) In the bathroom between resident rooms 6 and 5, there are exposed wall. The bathroom between resident room 1 and two, S1 stated that there was plumbing issues. AD stated "the drain backed up happened this morning and the maintenance worker is resolving it." Across from the washer and dryer machine, there is a ceiling wall that is damaged. In bedroom #10, LPAs observed a container of Ultra Clean Detergent which the door of bedroom #10 was not locked and the door was open and was accessible to residents in care. S1 removed the detergent during the visit. LPAs observed the bathroom near resident room 15, the wall had stains and the ceiling fan had lint. LPAs observed the fridge perpendicular to resident room #6 had stains and ice buildup and observed food on the ground. See LIC 809C. Page 1 of 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Pursuant to California Code of Regulations (CCR), Title 22, Division 6, deficiencies are being cited during today's visit based on LPAs observations, please see LIC 809D. The Department is issuing an immediate civil penalty of $250 for each repeat violation for the following deficiencies: 87303 Maintenance and Operation (a) was cited on February 22, 2024. An Exit Interview was conducted with the Administrator Designee which includes the review of this Evaluation Report and a provided copy of this report to the Administrator Designee. Appeal Rights were provided to AD. END OF REPORT. Page 3 of 3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 While touring the backyard, LPAs observed directly next to the bedroom 16 exit outside, has a garden tool that is accessible to residents in care. LPAs observed a storage shed next to the gazebo which had a window opened with tools and chemicals when reaching the window. LPAs observed the wood fence being propped to prevent the fence from falling. In the outside premises, the exterior door of Room #12, the screen door is not attached. In the exterior, one of the wood handrails for the ramp for Room #3 is fragile and wiggles when used as support. When entering the second story directly from the outside, LPAs observed in front of staff rooms, chemicals and tools are accessible to residents in care. LPAs randomly tested three (3) resident bathrooms where the water temperature is recorded between 112 to 116 degrees Fahrenheit. In the living room, there were facility activities occurring for the residents such as music performance. Based on a review, the fire department conducted an inspection of for the sprinkler system which was in February 2024. The fire extinguisher was last serviced on January 8, 2025. LPAs reviewed 4 Resident Records and 4 Staff Records. LPAs requested to review R1 to R4’s Appraisals Needs and Services. AD stated, “forms have not been filled out yet.” 3 out of 4 staff records did not have a signed Health Screening form by the Physician. LPAs also reviewed the Centrally Stored Medication and Destruction Record for 4 residents. LPAs reviewed facility disaster drill log, which stated January 25, 2025, was the last drill conducted. Additionally, LPAs audited the First Aid Kit, which has all the tools and equipment necessary for an emergency such as tweezers and scissors. LPAs requested a copy of the updated facility sketch plan. See LIC 809 C. Page 2 of 3.

This is a continuation of the required annual inspection done on 2/14/2024. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced continuation visit for the required annual inspection and met with administrator/house manager (ADM/HM) Randi Cabrera. Current census during today's visit is 20 residents 1 out of 20 is in rehabilitation, and 19 staff. LPA observed that the kitchen has a commercial grade gas stove with griddle and range hood. LPA observed that the range hood accumulated grease and grime that could pose imminent danger to persons in care. A used paper towel was observed stuck between the vent hood and the cabinet on the top left side. A used paper towel was placed on the griddle left bottom corner (photos were taken). Water temperatures for the bathroom and the kitchen was measured and ranges from 105 degrees Fahrenheit to 120 degrees Fahrenheit. During inspection of the facility, LPA observed that the conference room had an accordion door, behind the accordion door are facility’s decorating supplies (Christmas decors), 2 oxygen tanks, some furniture, and unused wheelchairs. The items in the room obstructed a designated emergency exit door. LPA observed a recliner upon exiting the door from the conference room, which obstructs the access to the walkway. LPA toured the residents’ and observed that emergency exits from the resident's room are clear from any obstructions, sliding doors are working and door alarms are in good working condition. LPA observed that residents’ rooms and common areas are clean and well maintained. All bathrooms have anti-skid mat and grab bars, sufficient supply of toilet rolls and paper towels. Resident rooms have ample storage, sufficient area for visiting families and clean beddings. Walkways inside the facility is clean and free from obstructions. continued to page 2 LIC 809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from Page 1 - LIC 809 page 2 of 3 While inspecting the exterior perimeter and the backyard LPA observed a gazebo near the maintenance shed with tools that are in the open and can easily be accessed and poses imminent danger to persons in care. From the kitchen exit to the exterior, LPA observed a garbage dumpster, a wheel burrow and asphalt compactor obstructing the walkway and gate towards the front exterior of the facility and designated as an emergency exit, LPA reviewed 5 resident records herein referred to as R1 to R5, and their centrally stored medication and destruction record (CSMDR). LPA observed that R1 has two expired medication that was not discarded and noted on the destruction record. R3 has medication that was not listed on the CSMDR. LPA reviewed the 5 staff record, herein referred to as S1 to S5 and found training and personnel record updated. The following deficiencies were cited based on the California Code of Regulations (CCR) Title 22. Deficiencies were observed on 2/14/2024 inspection and today's visit. (87303)(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors . 80087(d) Buildings and Grounds- All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. 87705 Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). continued to page 3 LIC 809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from page 2 page 3 of 3 Deficiencies continued. 87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (D)Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4). Any on-the-job training provided for the requirements in Section 87411(d)(4) may also count towards the requirement in this subsection. An exit interview was conducted with administrator/house manager Randi Cabrera and a copy of this report and appeals right was provided.

Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/03/2022 at 10:02am. LPA met with facility manager Kristine Cabrera (Admin). LPA began touring the facility inside and out including reception are, kitchen, dining room, offices, 10 bathrooms, 10 bedrooms, outside perimeter, storage rooms, and med room. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated. Facility Infectious Control plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. All restrooms were stocked with paper towels. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. Facility observed to have designated entry point. Staff took LPA's temperature, screened for symptoms, and recorded information in visitor log. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. 30 day supply of PPE observed. Fire Extinguishers observed to have been serviced on January of 2023. Carbon monoxide/smoke detectors were observed throughout the facility. Facility water temperature observed to be between 108.4*F and 150.2*F. Deficiency cited during today's visit. This report was reviewed with facility manager Christine Cabrera and a copy of the signed report was provided.