Routine inspection·October 26, 2023

On 10/26/2023 at 1:30PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Merla Fernandez, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator Edwin Liwanag via telephone. The Administrator currently holds a certificate (#6020847740) that expires on 10/23/2024. The facility’s fire clearance was approved for eight (8) non-ambulatory and two (2) bedridden residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) total bedrooms which and three (3) bathrooms. One (1) bedrooms is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. No bodies of water observed. A comfortable temperature is maintained at 67 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 102.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 09/16/2022. Emergency Disaster Plan was last posted on 02/18/2021. First aid kit was observed to be complete. Fire drill was last conducted on 03/16/2022. Continued on LIC809. Continued from LIC809. Four (4) staff records were reviewed and none have first aid certification. All six (6) resident records were reviewed and four (4) of six (6) did not have a current appraisal needs and services plan. LPA observed the following deficiencies: At 1:40PM, LPA observed knives and 2 pair of scissors sitting in container on kitchen counter. At 1:50PM, LPA observed there was not a 7-day of non-perishables and 2-day perishable foods available for the residents. At 1:55PM, LPA observed resident sitting in garage where Tide detergent, Clorox, and Lysol disinfect was accessible. At 2:10PM, LPA observed bathroom between bedrooms #6 and #4 door was being blocked in bedroom #6 by resident's bed, and staff using bedroom #4 to get to bathroom for staff use only. At 2:15PM, LPA observed oxygen tanks not on stands in R6's room. At 2:25PM, LA observed during record review that R1 and R6 was recently hospitalized and Administrator did not submit an incident report. At 2:35PM, LPA observed during record review that four (4) of six (6) residents did not have a current appraisal needs and services plan. At 2:40PM, LPA observed during record review that R1 and R6 did not have a home health agreement available for review. At 3:45PM, LPA observed during record review that S3 did not have a file available to review. At 3:50PM, LPA observed during record review that none of the staff have a first aid certification. Continued on LIC809C. Continued from LIC809C. LPA requested the following documents to be submitted to CCLD by 11/2/2023. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Resident roster 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 the appeal rights and this report and appeal rights provided.