Routine inspection·May 5, 2023

On 05/05/23 at 01:15 PM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced annual inspection. LPA met with Minoru Katsumoto, Administrator, and explained the purpose of the visit. ADM currently holds a standard certificate (6019180740 ) that expires 08/09/24. The facility’s fire clearance was approved for six (6) non-ambulatory residents; two (2) may have hospice waivers. Upon arrival LPA observed three (3) staff monitoring the facility and attending to residents that were watching television in the common area. LPA and ADM toured the facility including, but not limited to bathrooms, kitchen, common areas, laundry area, dining area, front yard and backyard. The facility consists of 5 (five) bedrooms. All outdoor and indoor passageways are free of obstruction. There were no bodies of water. A comfortable temperature was maintained at 71 degrees Fahrenheit (F). LPA observed lighting in all areas to be adequate for the comfort and safety of the residents. Hot water temperature in the shared residents' bathroom was measured at 110.5 degrees (F). All toilets, hand washing, and bathing areas were safe, sanitary and in operating condition. Hand washing signs, paper towels, and soap observed at all hand washing stations. Linen and hygiene products available for all residents. PPE, sanitizer, and paper goods remain sufficient. ...continued on LIC9099C ...continued from LIC9099. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was observed full and new tag to be replaced on 12/13/22. Emergency Disaster Plan is updated. Three (3) staff records were reviewed, and all staff have criminal record clearances. Five (5) residents records were reviewed and are incomplete. The following forms are to be updated and submitted to CCLD by 05/12/23 : -Resident Roster -LIC500 Personnel Report -LIC308 Designation of Administrative Responsibility -LIC610 Emergency Disaster Plan -Create emergency binder, organize staff and resident files with dividers and tabs and provide photos to CCLD by 06/05/23. Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Repeat violation(s) within a 12-month period and/or failure to correct deficiencies may result in civil penalties. Exit interview conducted, appeal rights and a copy of this report provided to ADM. Exit interview conducted and a copy of this report provided to ADM.