Routine inspection·May 28, 2025

On 05/28/2025 at 3:10 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee/Administrator, Obed D'Autruche and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of six (6) non-ambulatory and where one (1) bedridden resident can reside in Bedroom #1. Hospice waiver approved for two (2) residents. Administrator certificate #7008942740 expires 01/15/2026. LPA toured facility with Obed including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of five (5) total bedrooms which one (1) bedroom is occupied by one (1) resident and two (2) bedrooms are occupied by live-in staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 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 126, 128 and 128.7 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. Sharps were locked and inaccessible to residents. LIC809-C Continued... LIC809-C Continued... 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 05/28/2025. Emergency disaster drill was last conducted on 03/15/2025. LPA reviewed one (1) resident's records. LPA reviewed three (3) staff records and three (3) of four (4) have current first aid training and associated to the facility. LPA reviewed a sample of resident’s medications. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPA observed wooden coat rack, piece of wood lumbar, and other materials along the outside fence and back yard LPA observed a bed with sheets/blanket/pillows located in the garage LPA observed the flooring in rear bathrooms and shower were not clean LPA observed piece of wood flooring broken at rear bathroom Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/04/2025: Updated LIC 500 Personnel Report LIC 610E Emergency Disaster Plan - Reviewed Certificate of Liability Insurance 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. Exit interview conducted. Appeal Rights and a copy of this report provided.