Routine inspection·April 30, 2024

On 4/30/2024 at 10:30am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Mary Lorraine Adriatico, Caregiver , and explained the purpose of the visit. Ding Wang, Administrator arrived at 11:05am. The facility’s fire clearance was approved for four (4) ambulatory, one (1) non-ambulatory, and one (1) bedridden resident. Facility has a hospice waiver for two (2). LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) total bedrooms two one-half (2-1/2) bathrooms. LPA observed pool in the backyard has locked gate. A comfortable temperature is maintained at 71 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 100.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 04/24/2024. Emergency Disaster Plan was last posted on 9/1/2023. First aid kit was observed to be complete. Continued on LIC809. Continued from LIC809. LPA reviewed four (4) staff files. All five (5) residents' file were reviewed and a sample of resident's medication. LPA observed the following deficiencies: At 11:45am, LPA observed Comet can powder, Comet spray disinfectant in unlocked cabinet underneath kitchen sink. At 11:45am, LPA observed knives and scissors in unlocked drawer next to stove. At 12:00pm, LPA observed bathroom disinfectants and fabuloso in unlocked shared bathroom cabinet underneath sink. At 12:03pm, LPA observed R5 in a non-ambulatory room. At 12:05pm, LPA observed Comet underneath sink and toilet cleaner tablets in unlocked drawer in master bathroom. At 2:10pm, LPA observed closet doors, bed rails, shower doors, wooden planks, 2 wheelchairs, 2 walkers, and 3 commodes located on right side of facility in back yard. At 12:25pm, LPA observed facility has hospice waiver for two (2), but have three (3) hospice residents. At 3:00pm, LPA observed Administrator did not have a current administrator certificate. At 3:15pm, LPA observed R4 with full-bed rail and no doctor's order. Continued on LIC809C. Continued from LIC809C. LPA requested the following documents to be submitted to CCLD by 5/7/2024. Resident Roster LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan 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. *An immediate civil penalty of $500.00 for two (2) repeat violations will be assessed on today's date* Exit interview conducted. A copy of appeal rights, LIC421FC, and this report provided.