Routine inspection·June 3, 2024

On 6/3/24 Licensing Program Analyst (LPA) M. Garza and Licensing Program Manager (LPM) , S. Moua arrived unannounced for an annual inspection visit. LPA was met by Direct Care Staff, Joseph and Bae Chua. LPA and LPM introduced selves, explained reason for visit and were permitted entry into the facility. Designee, Carlo Santos was contacted and arrived some time later. A health and safety check on residents in care was completed. 4 of 5 residents present at time of visit. Residents observed in common areas and in rooms. Facility was toured inside and out. 2 of 6 residents currently receiving hospice services. Pathways and doors were clear and free from obstruction. Facility was clean and without odor. Common areas were clean, adequately furnished, and adequately lit. Smoke detectors and carbon monoxide detectors were present and operational at time of visit. Fire extinguisher last serviced 9/6/23. Last fire drill on 2/21/24. Water temperature measured 114.8 degrees F. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. Sharps and medications were located in locked cabinet/closet. LPA observed seating under covered patio areas. The following issues were observed during the visit: kitchen cabinets/drawers off track/broken and in need of repair, back sliding door not properly opening/closing, R5 was observed with hospital bed without a prescription, chemicals observed in R1's bathroom unlocked and accessible to residents in care. LPA requested the following documents to be submitted to CCL by 6/10/24: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Affidavit regarding Resident Cash Resources (LIC 400), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file. Deficiencies cited per Title 22. Exit interview completed with Designee, Carlo Santos. A copy of this report, deficiencies, TV's and appeal rights provided.