Routine inspection·June 21, 2024

On 6/21/2024 at 7:55 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Warlita Agmata-Rivac and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory. LPA toured facility with Warlita Agmata-Rivac including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are for the residents and 1 bedroom is occupied by staff. 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 the residents’ shared bathroom was measured at 113.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 8/11/2023. Emergency Disaster Plan was last posted on 1/1/2024. First aid kit was observed to be complete. At 8:15am, LPA reviewed 5 residents records. At 11:00am, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. Report continues on LIC809-C THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 8:00am LPA observed a bed set up in the living room that is used by staff to sleep on during the night. Administrator confirmed that the staff sleep on the bed. Also At 9:40am during facility tour LPA observed that in the backyard a shed has been converted and is being occupied by a caregiver. The structure is not cleared on the facility sketch and Administrator confirmed that the shed was converted after the last annual inspection was conducted. (Repeat Violation: 87307(a)(2)(B) ) $250 At 8:30am during file review LPA observed that R2 does not have an Needs and Services Plan. Administrator confirmed they have not done the appraisal. (Repeat Violation: 87506(b) ) $250 At 8:50am during file review LPA observed that R3's physicians report lists them as BEDRIDDEN. LPA contacted the primary care physician to confirm this diagnosis. Physician confirmed resident is bedridden. Facility is not cleared for bedridden. (Immediate Civil Penalty: 87202(a)(2) ) $500 At 9:28am during facility tour LPA observed the dishwasher being used as a storage place for dishes. LPA observed a large cooking knife with a yellow handle stored inside. Administrator removed and locked away knife. Also at 9:29am during facility tour LPA observed ZZZQuil unlocked in the bottom kitchen counter. Administrator removed and locked away PRN. At 10:17am LPA contacted desk duty to inquire about the status of the Administrators certificate. There is no certificate application pending. The last certificate expired 12/17/2021.(Repeat Violation: 87412(d) ) $250 At 11:22am during file review LPA did not observe a disaster drill on file. Administrator states they have not done any drills this year. ***An immediate civil penalty is being assessed today for $500 for fire clearance violation 87202(a)(2)*** **A civil penalty is being assessed today for $750 for all other repeat violations {$250 per violation x 3}** Civil penalty total= $1,250 The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.