Routine inspection·November 6, 2023

On 11/06/2023 at 12:30 PM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Ding Wong and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Non-Ambulatory which 1 may be Bedridden. LPA toured facility with Ding including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which all 6 bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 76 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 bathrooms were measured within range of 105-120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguishers were observed. First aid kit was observed to be complete. At 12:55 PM, LPA reviewed 5 of 5 residents records. At 2:30 PM, LPA reviewed 4 of 7 staff records and 4 of 4 have first aid training and associated to the facility. At PM, LPA reviewed a sample of 5 of 5 resident’s medications. Report continues on 809 C Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/27/2023: 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 The following deficiency was observed during inspection: -At approximately 1:00 PM LPA observed that the facility admitted resident (R1) with a prohibited health condition. Based on record review R1 has a Gastrostomy "g-tube" (feeding tube). -At approximately 1:28 PM LPA observed that R2 was also admitted with a prohibited health condition. Based on record review R2 has a Gastrostomy "g-tube" (feeding tube). -At approximately 1:35 PM LPA observed that R3 was also admitted with a prohibited heath condition. Based on record review R3 has a Gastrostomy "g-tube" (feeding tube). -At Approximately 1:54 PM Administrator informed LPA that R4 was also admitted with a prohibited health condition. Based on record review R4 has a Gastrostomy "g-tube" (feeding tube). -At approximately 2:32 PM LPA observed that staff personnel records were missing forms. S1 and S2 staff files are missing LIC 501, LIC 503 and LIC 508. S3 staff file is missing LIC 503 and LIC 508 The following deficiencies were observed (see LIC 809 D) 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 and a copy of this report provided along with Appeal rights