Routine inspection·June 30, 2023

On 6/30/2023 starting at 10:00 AM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct 1-Year Annual Required Inspection. LPA met with Warlita Agmata-Rivac, Administrator (ADM) and explained the purpose of the visit. Administrators certificate (6007524740) expired on 12/17/2021. The facility’s fire clearance was approved for six (6) non- ambulatory residents, which all 6 may be on hospice. Upon entry, LPA observed one (1) staff and two (2) residents present during inspection. Starting at 10:20 AM, LPA toured facility with ADM including but not limited to six (6) bedrooms, three (3) bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all 6 bedrooms are private. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 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 114.3 Degrees Fahrenheit. Residents’ bathrooms are equipped non-skid mats. There is a minimum of one-week supply of nonperishable and 2-day supple of perishable foods. Sharps and toxins 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 7/7/2021. First aid kit was observed to be complete. Continue on Lic809-C Continued from Lic809 Starting At 11:50AM, LPA reviewed 2 of 2 staff records. At 12:27 PM, LPA reviewed 3 of 3 residents' record. At 1:02 PM, LPA reviewed a sample of 3 of 3 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 10:27AM, LPA observed a bed in the living room that staff are sleeping on. 2. At 11:12AM, LPA observed S2 does not have current administration certificate on file; Certificate expired on 12/17/2021. 3. At 12:00PM, LPA observed S1 with no first aid and CPR training on file 4. At 12:08PM, LPA observed S1 with no Lic500 (personnel record), Lic503 (Health screening), and Lic508 (Criminal record statement) on file. S2 does not have an Lic508 on file. 5. At 12:40PM, LPA observed during record review that R1, R2, and R3 with no Lic625 (Needs/service plan) on file. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 7/7/2023: · 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 and a copy of this report provided.