Routine inspection·January 10, 2024

Licensing Program Analyst (LPA) A Gomez conducted an unannounced 1-Year Annual Required visit on this date starting at 1:20pm. Upon arrival, LPA met Administrator, Josefina Gardner. The facility's fire clearance was approved for six non-ambulatory. Administrator holds a current certificate (#6015433740) that expires 04/09/2024. During the visit, LPA toured facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, backyard and common areas. A comfortable room temperature is maintained at 73 degrees F. Hot water temperature measured at 114.7 degrees F. There is a minimum of 2-day perishable and one week perishable foods. Indoor and outdoor passageways were kept free of obstruction. There are no bodies of water observed. LPA observed resident's shared bathrooms were equipped with grab bars and non-skid mat. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last bought on 1/10/2024. Emergency Disaster Plan was last posted on 10/20/2023. Fire drill was last conducted on 4/27/2023. First Aid kit was observed complete. LPA reviewed 3 staff records and 3 of 3 staff are associated to the facility and have current first aid training. LPA reviewed 4 residents records and a sample of residents medications. Report continues on 809C The Following Deficiencies were Observed: During Tour LPA observed unlocked cleaning supplies (comet, windex, Clorox cleaner, ect) under kitchen sink and under bathroom sink. Administrator removed and locked away all chemicals clearing the deficiency. Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 1/19/2024: 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. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.