Routine inspection·March 23, 2023

On 3/23/2023 starting 10:00 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPAs were greeted by Caregiver, Jimmy Payna and LPAs explained the purpose of the visit. Back-up Administrator, Marjorie Osia later arrived at 10:30 AM. The facility’s fire clearance was approved for all six (6) residents may be non-ambulatory. There were 5 staff of which 2 were off-duty and 6 residents present during inspection. Starting at 10:45 AM, LPAs toured facility with back-up Administrator including but not limited to 6 bedrooms, 3 bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are for residents and 1 bedroom is for staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in 1 of 3 residents’ shared bathroom was measured at 115 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 5/7/22. Emergency Disaster Plan was last posted on 1/6/23. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 1/6/23. REPORT CONTINUES ON 809C At 12:20 PM, LPAs reviewed 5 residents records. At 1:15 PM, LPAs reviewed 3 staff records. At 3:10 PM, LPAs reviewed a sample of resident’s medications. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: -At 10:15 AM, LPAs observed S2 is not associated to the facility -At 1:38 PM, LPAs observed S3's first-aid cert expired 3/11/22 Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 3/31/2023: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate 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.