Routine inspection·January 24, 2025

On 01/24/2025 at 10:25AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Caregiver Gilbert, Villota spoke with Administrator, Shahid Siddiqui via telephone, and explained the purpose of the visit. The Administrator currently holds a certificate (#6043867740) that expires on 03/15/2025. The facility’s fire clearance was approved for eight (8) non-ambulatory residents. Administrator had to leave during visit and gave authorization to Gilbert Villota, Caregiver to sign reports. LPA toured the facility with Caregiver, Gilbert Villota including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of seven (7) bedrooms and four (4) bathrooms. one (1) bedroom occupied by staff. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 75 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 119.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non skid 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 11/14/2024. Emergency Disaster Plan was last posted on 02/05/2024. First aid kit was observed to be complete. Fire drill was last conducted on 09/14/2019. Continue on LIC809C Continued from LIC809. Four (4) staff records were reviewed, three (3) staff members were missing annual training, S4 wasn't associated and was missing Health Screening . LPA reviewed all five (5) resident records, and they were incomplete. LPA requested the following documents to be submitted to CCLD by 01/31/2025 . · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan (last page) · Liability Insurance LPA observed the following deficiencies: At 11:20AM, LPA observed all five residents has hospital beds with bed rails At 12:15PM, LPA observed during file review all five residents files were incomplete At 12:30PM, LPA observed during file review three (3) out of four (4) staff did not have annual training and S4 was missing Health Screening and was not associated to the facility 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 of this report, appeal rights and LIC412FC provided