Routine inspection·October 5, 2023

Licensing Program Analysts (LPAs) A. Gomez and P. Watson conducted an unannounced 1-year Required visit on this date. LPAs met and toured with Administrator, Ana Breen. The Administrator currently holds a certificate (#6051319740 ) to expire on 2/28/2025 . The facility’s fire clearance was approved for six (6) non-ambulatory residents and subject to three (3) hospice waivers. LPAs toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of six ( 6) total bedrooms which three (3) bedrooms are occupied by the residents and three (3) bedroom is occupied by staff.A comfortable temperature is maintained at 77 degrees Fahrenheit. LPAs 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 108 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 2-day of perishable foods and a minimum 7-day non-perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/10/2022 . First aid kit was observed to be complete. Report continues on 809C At 9:55AM LPAs reviewed two (2) staff record files and staff have criminal record clearance and are associated to the facility. 2 of 2 staff have current first aid training. LPAS reviewed two (2) resident's records. The following deficiencies were observed: 10:25AM LPA's observed moldy and expired food in kitchen fridge and pantry 10:29AM LPA's observed unlocked knives on counter (cleared during visit) 10:30AM LPA's observed the inside of the facility to be cluttered and dusty throughout common areas 10:32AM LPA's observed laundry room piled with clothes and unlocked detergent. 10:44AM LPA's observed oxygen tanks without stands in residents (R1) room with no posted signs. 10:59AM LPA's observed unlocked can of RAID bug spray in residents bathroom under sink. 11:09AM LPA's observed clutter and various items in yard (items include but are not limited to: car parts, rusted box springs, mattresses, tires, and other miscellaneous items) 11:10AM LPA's observed the backyard fence in disrepair (fence located on left side of house) 11:11AM LPA's observed an unlocked pool area with a partial fence that is the incorrect height (fence measured below 5 feet) Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties. Report continues on 809C (2) LPA requested the following documents to be submitted to CCLD by 10/12/2023. · Resident Roster · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan (9 pages) · Liability Insurance Exit interview conducted. A copy of appeal rights and this report provided .