Routine inspection·November 3, 2023

Licensing Program Analysts (LPAs) A. Gomez and L. Hall arrived unannounced to conduct 1-Year Annual Required visit on this date starting at 1:20pm. Upon arrival, LPA met with Caregiver Engracia De Jesus and explained the reason of the visit. Administrator unavailable. The facility's fire clearance was approved for six non-ambulatory. LPA toured facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of six (5) total bedrooms which all 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 70 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 107.6 degrees F. 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 are locked and inaccessible to residents. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/01/2021 . Emergency Disaster Plan is posted. First aid kit was observed to be complete. Fire drill was last conducted on 12/30/2023 . LPA reviewed 4 staff records and 3 of 4 staff have current first aid training and associated to the facility. LPA reviewed 4 residents records and 4 of 4 residents have current medical assessment. Report continues on 809C The following deficiencies were observed: At 1:50pm during staff file review LPA's observed 1 (S4) missing physicians reports and TB test At 2:00pm LPA's observed fire extinguisher to have been last serviced 12/01/2021 At 3:00pm LPA's observed bedridden resident placed in room 2. Room 5 is only room cleared for bedridden At 3:20pm LPA's observed that there is no current administrator certificate on file Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 11/20/2023: · 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 . Updated Facility Sketch *An immediate civil penalty of $500.00 will be assessed on today's date for a fire clearance violation* The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Caregiver. A copy of this report, LIC421M and appeal rights provided.