Routine inspection·June 12, 2024

On 06/12/2024 at 11:10AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct an Annual 1-Year required inspection. LPA met with Maupuku Ofahengaue, Caregiver and explained the purpose of the visit. Maupuku, caregiver contacted the administrator via telephone and explained my purpose of visit. Crystal Vaka, Administrator, arrived at 11:54AM. Administrator currently holds a certificate #6051305740 Expires 04/03/2025. The facility’s fire clearance was approved for six (6) Non ambulatory residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and four (4) bathrooms. LPA did observe an enclosed swimming pool in the backyard. A comfortable temperature is maintained at 78 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 103.9 degrees Fahrenheit. Residents' bathrooms are equipped with grab bars and nonskid mats. 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 10/24/2023. Emergency Disaster Plan was last posted on 09/01/2023. First aid kit was observed to be complete. Fire drill last conducted on 09/01/2023. Continued LIC809C. Continue from LIC809 LPA reviewed all three (3) residents records and three (3) staff records were reviewed. LPA also reviewed a sample of medication LPA requested the following documents to be submitted to CCLD by 06/19/2024. · LIC 200 Application for a Community Care Facility ..... · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan (last page) · Liability Insurance · Updated Facility Sketch LPA observed the following deficiencies: At 11:46AM LPA observed unlocked medicine in cabinet located in the kitchen area At 12:00PM LPA observed a swimming pool in the back yard with unsecured lock around the gate At 12:10PM LPA observed an unlocked cabinet the common bathroom with windex and pine sol and fabuloso antibacterial multi purpose cleaner on counter near sink At 12:28PM LPA observed resident in room #2 in a medical bed with a Half (1/2) bed rail Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. 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 the appeal rights, and the report provided.