Routine inspection·July 10, 2023

On 07/10/2023 at 8:45 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with House Manager, Mateaki Ofahengaue and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory. LPA toured facility with Mateaki including but not limited to bedrooms, bathroom, kitchen, common area and backyard. The facility consists of 5 total bedrooms which all 5 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed . A comfortable temperature is maintained at 69 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 120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7 day 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 detectors were in operating condition during visit. Fire extinguisher was last purchased on 9/25/2022. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/03/2023. Report continues on 809 C. At 9:25 AM, LPA reviewed 4 of 4 residents records. At 11:18 AM, LPA reviewed a sample of 4 of 4 resident’s medications. The following deficiency was observed during inspection: -At approximately 9:40 AM, LPA observed Resident 1 (R1), Resident 2 (R2) and Resident 4 (R4) resident records were incomplete. R1 binder was missing LIC 602A, LIC 625, LIC 601, Consent Forms and LIC 613. R2 binder was missing Consent forms, LIC 601 and LIC 613. R4 binder was missing LIC 625, LIC 601, Consent Forms and LIC 613. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/31/2023: 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 809 D) and cited from the California Code of Regulations, Title 22 and 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.