Routine inspection·September 23, 2023

On 9/23/2023 at 12:45PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Pamela Green, Administrator and explained the purpose of the visit. The Administrator currently holds a certificate (#6024026740) that expires on 02/10/2025. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) total bedrooms which one (1) bedroom is occupied by staff, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 70 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 114.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/18/2023. First aid kit was observed to be complete. Continued on LIC809. Continued from LIC809. LPA reviewed three (3) staff files all are incomplete. All four (4) residents' file were reviewed and all were incomplete. LPA observed the following deficiencies: At 1:00pm, LPA observed during record review all of the resident files are incomplete. At 1:30pm, LPA observed during record review all three (3) staff files are incomplete. At 1:35pm, LPA observed during record review two (2) of three (3) staff do not have first aid certification. LPA requested the following documents to be submitted to CCLD by 10/2/2023. Resident Roster LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report provided.