Routine inspection·May 31, 2023

q1On 4/25/2023 starting at 1:10 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with care staff and and explained the purpose of the visit. Administrators certificate (6006422740) is valid and expires on 8/2/2023. The facility’s fire clearance was approved for all six (6) non- ambulatory residents, which facility is granted for two (2) hospice waivers. Upon entry, LPA observed two (2) staff and four (4) residents present during inspection. At 11:02 AM, LPA met and was greeted by Mirriam Paras- Administrator (ADM). Starting at 10:35 AM, 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 all 5 bedrooms are private and one bedroom is a staff room. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 Degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients'. The hot water temperature in residents ’ common area bathroom was measured at 119.6 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 were locked and inaccessible to residents'. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was observed last serviced on 4/4/2019. First aid kit was observed to be complete. Continue on Lic809-C Continued from Lic809 Starting At 11:30 AM, LPA reviewed 3 of 3 staff records. At 12:43 PM, LPA reviewed 4 of 4 residents' record. At 2:05 PM, LPA reviewed a sample of 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 10:50AM, LPA observed fire extinguisher in common area room expired on 4/4/2019. 2. At 12:30PM, LPA observed S1, S2, and S3 do not have current First aid and CPR training on file. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 4/5/2023: · LIC 308- Designation of Administrative Responsibility · LIC 500- Personnel Report · LIC 610E- Emergency Disaster Plan (9 Pages) · Liability Insurance Exit interview conducted with ADM, appeal rights given along with a copy of this report.