Routine inspection·May 18, 2023

On 5/18/2023 at 1:45PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Mary Lorraine Adriatico, Direct Support Professional (DSP) and explained the purpose of the visit. Ding Wang, Administrator arrived at 2:50PM. The Administrator currently holds a certificate (#6055098740) that expires on 01/29/2024. The facility’s fire clearance was approved for four (4) ambulatory, one (1) non-ambulatory, and one (1) bedridden resident. LPA toured the facility with DSP including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) total bedrooms which one (1) bedroom is occupied by staff, and two one-half (2-1/2) bathrooms. LPA observed pool in the backyard has locked gate. A comfortable temperature is maintained at 79 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 129.6 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. 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 01/20/2023. Emergency Disaster Plan was last posted on 10/08/2022. First aid kit was observed to be complete. Fire drill was last conducted on 03/16/2022. Continued on LIC809. Continued from LIC809. Facility did not have Administrator file available and staff file was not complete. All three (3) residents' file were reviewed and all were incomplete. LPA observed the following deficiencies: At 1:50PM, LPA observed an inoperable microwave sitting outside in the driveway. At 2:00PM, LPA observed 2 bottle of melatonin, a bottle of joint pills in unlocked kitchen drawer. At 2:03PM, LPA observed oven cleaner, Odoban disinfectant and Pine-Sol in unlocked cabinet underneath kitchen sink and a pair of scissors in utensil holder on kitchen counter. At 2:05PM, LPA observed a room built for staff in garage. At 2:07PM, LPA observed medication closet with medication in it unlocked. At 2:10PM, LPA observed Ajax and a bottle of disinfectant in 1/2 bathroom in unlocked cabinet underneath the sink. At 2:15PM, LPA observed two (2) shower glass doors, a wooden bed frame, a shovel, and a rake in passageway on left-side of house. At 2:18PM, LPA observed drawers, a ladder, and a bed frame in passageway on right-side of house. At 2:40PM, LPA observed during record review that R3 had been hospitalized several times (6). Administrator did not report hospitalization to CCLD. At 3:35PM, LPA observed during record review that the facility does not have a personnel file for S1 or a complete file for S2 (1st Aid, CPR, health screening, TB, employee rights, training records) At 3:40PM, LPA observed during record review resident records were incomplete. Continued on LIC809C. Continued from LIC809C. LPA requested the following documents to be submitted to CCLD by 5/25/2023. Resident Roster LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties. Exit interview conducted. A copy of appeal rights and this report provided.