Routine inspection·October 19, 2023

Licensing Program Analysts (LPA) A. Gomez and Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to conduct a 1-Year Annual Required visit on this date starting at 10:40AM. Upon arrival, LPA and AGPA met with Executive Director, Rachael Davis. The facility's fire clearance was approved for all may be non-ambulatory of which 8 may be bedridden. LPA and AGPA toured the facility inside and out with Executive Director including but not limited to facility hallways, activity room, dining room, kitchen, resident rooms and medicine room. Indoor and outdoor passageways were kept free of obstruction. There are no bodies of water observed. Hot water temperature in random resident's bedroom was maintained at 113.6 degrees F. In another Residents room, hot water temperature was maintained at 114.1 degrees F. A comfortable room temperature was maintained at 73 degrees F in the hallway. Facility was equipped with a minimum of one week supply of non-perishable and 2-day supply of perishable food. Medication carts were observed locked. LPA's reviewed a sample of medication. Fire extinguisher was last serviced on 09/12/2023. Smoke detectors and sprinklers are interconnected and observed throughout facility. LPA and AGPA reviewed 5 staff records and 5 of 5 are associated and have current first-aid training. LPA reviewed 5 residents records. The following deficiencies were observed At 12:17PM LPA's observed Miralax in R4's apartment. At 12:35PM LPA's observed TUMS in R5's apartment. REPORT CONTINUES ON 809C Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 11/02/2023: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate 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 with Executive Director. Appeal Rights and a copy of this report provided.