Routine inspection·August 11, 2023

On 8/11/2023 starting at 1:25 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Care staff- Noel Morales and explained the purpose of the visit. The facility’s fire clearance was approved for all six (6) non- ambulatory residents' and are allowed 4 hospice residents. Upon entry, LPA observed two (2) staff and four (4) residents present during inspection. Starting at 1:43 PM, LPA toured facility with care staff including but not limited to six (6) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 2 bedrooms are private, 2 rooms are shared, and 2 staff rooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 78 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents'. The hot water temperature in residents’ common area bathroom was measured at 110.4 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supply of perishable foods. Sharps and toxins were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was observed last serviced on 8/2/2023. First aid kit was observed to be complete. Continue on Lic809-C Continued from Lic809 Starting at 2:21PM, LPA reviewed 4 of 4 residents' records. At 3:09 PM, LPA reviewed 4 of 4 residents ' medications. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. 1. At 2:00PM, LPA interviewed licensee and licensee stated that she does not have the staff files in the facility and are misplaced. 2. At 2:30PM, LPA observed during record review that, R2 and R4 do not have a needs and service place in their files. 3. At 2:43PM, LPA observed during record review that R4 does not have an admission agreement on file. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/18/2023: · LIC 308 Designation of Administrative Responsibility · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan (9 Pages) · Liability Insurance Exit interview conducted with care staff, and a copy of this report provided along with appeal rights.