Routine inspection·October 12, 2023

Licensing Program Analysts (LPAs) A. Gomez and K. Nguyen conducted an unannounced 1-year Required visit on this date. LPAs met and toured with Administrator, Sheila Melencion . The Administrator currently holds a certificate (#602427740 ) that expires on 5/11/2023 and is currently in process of receiving new certificate . The facility’s fire clearance was approved for a capacity of 18 which 16 may be non-ambulatory and subject to five (5) hospice waivers. LPAs toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. 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. LPAs observed lighting in all rooms that are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 116.2 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. Report continues on 809C Smoke detectors and carbon monoxide were in operating condition during visit. LPAs observed sprinklers throughout the facility. Fire extinguisher was last serviced on January 25, 2022 Fire Drill was last conducted on January 8, 2022 . First aid kit was observed to be complete. LPAs reviewed 3 staff records and staff have criminal record clearance and are associated to the facility. 3 of 3 have current first aid training. LPAs reviewed 4 residents’ records. The following deficiencies were observed: 1:00pm LPA's observed the MAR to be incomplete and not up to date. LPA requested the following documents to be submitted to CCLD by 10/21/2023 . · 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 The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided .