Routine inspection·July 27, 2023

On 7/27/2023, starting at 12:15 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Care staff, Gloria Zulueta, and explained the purpose of the visit. The facility’s fire clearance was approved for all six (6) non- ambulatory residents. Upon entry, LPA observed one (1) staff and three (3) residents' present during inspection. At 12:30 PM, Licensee gave consent to care staff to tour and sign todays report on Licensees behalf. Starting at 12:40 PM, LPA toured facility with care staff including but not limited to four (4) bedrooms, two (2) bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 2 bedrooms are private, and 2 bedrooms are shared. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 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 106.4 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day 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 11/9/2022. First aid kit was observed to be complete. Continue on Lic809-C Continued from Lic809 Starting At 1:21 PM, LPA reviewed 1 staff record. At 1:40 PM, LPA reviewed 3 of 3 residents' record. At 2:22 PM, LPA reviewed a sample of 3 of 3 residents' medication. LPA interviewed 1 staff at 2:30 PM and interviewed 2 clients at 2:32 PM. 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 1:47 pm, during record review, LPA observed R1 does not have a complete Lic625 (Needs and service plan) in residents file. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/4/2023: · LIC 308- Designation of Administrative Responsibility · LIC 500- Personnel Report · LIC 610E- Emergency Disaster Plan (9 Pages) · Liability Insurance Exit interview conducted with ADM, and a copy of this report provided.