Routine inspection·October 18, 2024

On 10/18/2024 at 12:45 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Evangeline Lekse and explained the purpose of the visit. The facility’s fire clearance was approved for six (6) non-ambulatory. Hospice waiver for two (2). Administrator certificate #6024122740 expires 03/08/2025. LPA toured facility with Evangeline including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven (7) total bedrooms which six (6) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 72 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 105 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. Centrally stored medication and sharps were locked and inaccessible to residents. LIC809-C Continued... Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 09/10/2024. Emergency Disaster Plan was last posted on 04/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 07/20/2024. LPA reviewed five (5) residents records. LPA reviewed three (3) staff records and 3 of 3 have current first aid training and associated to the facility. 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. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/25/2024: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan - Reviewed Liability Insurance Exit interview conducted. Appeal Rights and a copy of this report provided.