Routine inspection·January 23, 2025

On 5/12/23 Licensing Program Analysts (LPAs) M. Garza and L. Salazar arrived unannounced for an annual inspection visit. LPAs were met by Direct Care Staff, Esther and Henry Alsisto explained reason for visit and was permitted entry into the facility. Administrator, Jasmine Oganyan was contacted and arrived some time later. LPAs completed a health and safety check on residents in care. LPA toured the facility inside and out. Residents observed in common areas and in rooms. There was 4 residents on hospice and 2 bedridden at the time of visit. 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 1/7/25. Last fire drill on 11/24/24. Resident rooms observed to have the required furnishings and with adequate lighting. Linen supplies are kept in linen closets. LPA observed sufficient seating under covered patio areas. The following issues were observed during time of visit: Facility sketch needs meeting point designated. 2 of 6 residents observed with hospital beds with hand railings and not on hospice. Bathroom #2 floor is not slip-resistant. Air vents in Bathroom #2 is rusted/dirty and in need of cleaning/replacement. Bathroom #2 baseboard in need of repair/replacement. Bathroom #2 light switch broken and in need of repair. Fence on right side leaning and in need of repair. Debris observed in pool area in need of removal. Concrete walkway in back of house observed with a lip (possible tripping hazard) in need of repair. Debris observed by storage shed in need of removal. CONT... CONT... Chemicals/sharps/items posing danger to residents observed throughout the facility unlocked and accessible. First Aid kit missing instruction guide. Bedroom #6 observed with a broken window in need of repair. Pool fence in need of repair. Quick release bars observed on windows. An immediate danger was not observed for pool fence due to the non-ambulatory status of the residents and their inability to leave the facility without assistance. The Department will review original fire clearance for approval of window bars. If deficiency is warranted, they will be issued at a later time. Immediate civil penalty assessed in the amount of $500 for bedridden resident. LPA requested the following documents to be submitted to CCL by 1/31/25: current copy of Administrator’s Certificate, Administrator Organization (LIC 309), Designation of Administrative Responsibility (LIC 308), Emergency Disaster Plan (LIC 610-E), Personnel Report (LIC 500), Register of Facility Clients/Residents (LIC 9020) in order to update the facility file. Exit interview completed with Administrator, Jasmine. A copy of this report, deficiencies and TV's provided.