Routine inspection·May 29, 2024

On 05/29/2024 at 1:05 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Obed D'Autruche and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of 4 (four) and hospice waiver for 2 (two). Administrator Certificate # 6030033740 expired 01/15/2024. Administrator stated that he submitted his renewal application which was dated 04/01/2024. LPA toured facility with Obed including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 2 bedrooms are occupied by the residents and 3 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 77 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 113.5 degrees Fahrenheit. 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 were locked and inaccessible to residents. Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 05/08/2024. Emergency Disaster Plan was last posted on 05/29/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 03/28/2024. LIC809-C Continued... LIC809-C Continued... LPA reviewed 3 residents records. LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/05/2024: 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 Exit interview conducted. Appeal Rights and a copy of this report provided.