Routine inspection·September 28, 2023

On 9/28/2023, Licensing Program Analysts (LPAs) K. Kaur and L.Padgett arrived unannounced at the above facility to conduct an Annual Inspection. LPAs introduced themselves, stated the purpose of the visit and met with Administrator MaDavina (Grace) Petil (AD). LPAs conducted facility tour with AD and Staff Tirso Petil (S1). LPAs toured kitchen and dining areas. The kitchen was observed clean, in good repair with necessary items and appliances. LPA observed non-perishable and perishable foods. Carbon monoxide detector in the kitchen was tested operational. Smoke detectors were observed in all bedrooms and the hallways, tested, observed operational. Office is in converted garage space. In the laundry room, detergent and cleaning supplies are kept in locked cabinets. LPAs observed facility common areas which were furnished with sufficient seating. LPAs toured five resident rooms which were observed to be furnished with required furniture and adequate lighting. At 9:05am LPAs observed some dust debris in resident bedrooms. LPAs observed one cracked tile and slight lift on the transition floorboard at the entrance of bedroom 5. Bathrooms were properly equipped with non-slip mats and grab bars. At 9:43 AM Padgett tested water temperature in the hallway bathroom sink at 92.8°F and the bathroom in bedroom 5 91.4°F. At 9:41am LPA Kaur observed 5 out of 5 stove knobs accessible to residents while no staff were present in the kitchen and or cooking. Bedroom 5 has door that leads to the backyard. LPA Kaur attempted to open this door, but it was stuck and difficult to open. S1 was able to open the door. Once this door was open, LPA’s observed what appears to be water damage and rot at the inner right corner of the door at the base. This exit opens to covered patio area with sufficient seating and shade for recreational purposes. There was visible rot and damage to the fascia and roof of the patio. On the patio roof area just above the Bedroom 5 exterior door is a gap between the home fascia and the patio fascia. Continued to next Page There, the roof area appears to be rotting. R2 stated that when it rains the covered patio area floods. Backyard gate was self-closing and self-latching. At 2:35pm LPA Kaur observed Fire extinguisher in kitchen was expired with a service date of July 20, 2022. Medications are kept in locked pantry in the kitchen. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. AD stated that she and S1 are the only employees. Staff files were reviewed for health screening and first aid/CPR certified. Last fire drill conducted on 8/7/2023. At 1:20 PM LPA’s reviewed resident's medication, MARS, and Centrally Stored Medication and Destruction Record (CSMDR) and observed (R1) and (R4) did not have a Centrally Stored Medication and Destruction Record. During Resident records review 2 of the 5 residents were observed to be without TB clearance. Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6. LPA is requesting the following documents be submitted to the Fresno CCL office by 10/5/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan, Personnel Report (LIC500), Register of Facility Clients/Residents LIC9020. An exit interview was conducted with Administrator. Report signed on-site; a copy of this report, 809D with appeal rights were provided.