Routine inspection·September 18, 2024

On 9/18/2024 at 12:30 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Caregiver, Tito Lacuesta Jr and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory and a hospice waiver for 2. Clients were at day program during visit. LPA spoke with the Administrator over the phone and was told Tito could sign the report. LPA toured facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. 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 125.1 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. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 10/4/2023. Emergency Disaster Plan was last posted on 9/18/2024. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/8/2024. At 1:00pm, LPA reviewed 6 of 6 residents records. At 1:30pm, LPA reviewed 4 staff records and 4 of 4 have current first aid training and associated to the facility. LPA observed P&I log to be correct and Facility has a sufficient surety bond. REPORT CONTINUES ON LIC 809-C THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 1:51pm LPA observed a box of medications unlocked and unsecured in the sliding door closet by the front door At 1:55pm LPA observed that the facility had been altered and was not matching the approved facility sketch. A door has been installed in room 1 that the staff use to have access to the designated staff room. The approved door has been blocked by a cabinet. Due to alteration clients privacy and personal rights are being violated by staff needing to use their bedroom as a way to access the bathroom and staff room. At 1:57pm LPA measured the hot water temperature and it was 125.1 degrees F. 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. Exit interview conducted. Appeal Rights and a copy of this report provided.