Routine inspection·January 26, 2023

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual visit. LPA met with facility staff, and explained the purpose of the visit. Upon arrival, LPA noticed construction work in the front entrance of the building. LPA took pictures for reference. The facility is a two story building. In order to enter the facility, a person needs to walk across a bridge walkway. According to staff, the facility started working on the new walkway a few weeks ago. The new and temporary ramp was installed this week. LPA was not made aware of the repairs. LPA requested the building permit. Licensee Ron R. came to the facility around noon and gave LPA the building permits and construction blue print. A technical advisory was given regarding notifying CCL of any repairs or modification done to the facility. Title 87305 Alterations to Existing Building or New Facilities was discussed with Licensee and Executive Director (ED) Fleta Herndon. LPA toured the facility to ensure compliance of title 22 regulations. LPA toured the facility with facility staff. Hot water was measured at 108.7*F in two bathrooms. The facility common areas, including the activity room, dinning hall, day room, and hallways, were observed to be organized and free from debris. The elevator inspection is up to date. Fire extinguishers are up to date and fully charged. After the tour, LPA was met by Licensee Ron and ED Fleta. LPA discussed findings of the tour with ED and Licensee. The ED designated the lead staff on shift to sign off on the report. During the tour, LPA observed room 113. This is a empty resident room on the bottom floor. LPA observed construction items, bed frames, unused mattresses, and other tool items in the room. LPA heard voices in the bathroom. According to interviews, this room is utilized by staff to give showers to residents due to the walk in shower. Licensee was informed of the situation and had hazardous items removed from the room into another vacant room. Continues on LIC 809 - C... Page 1 of 3 Continued from LIC 809 LPA was at the facility for majority of the day. During this time, there were no planned activities for the residents. According to staff, today is the activities director day off. LPA observed a staff member telling a resident there were no activities for the day. LPA requested the following copies: LIC 500, LIC 308, Liability Insurance, LIC 90999 - Current Facility sketch with current emergency exits, LIC 610E Current Disaster Plan Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiencies are being cited. Appeal rights were provided. An exit interview was held with staff, and a copy of the report provided. LPA to send copies of the report to ED Fleta Herndon and Assistant Administrator Loreen Hickman. .