Routine inspection·February 18, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 10:50 AM. LPA met with facility staff who contacted the facility backup Administrator Tina Arutyunyan. The backup Administrator arrived to the facility at 11:40 AM. Entrance interview conducted and the reason for the visit was explained. Beginning at 10:52 AM, the LPA, along with facility staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN : The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed a secured cabinet to contain resident medications. LPA observed a properly secured under-sink cabinet to contain cleaning supplies. LPA observed the laundry closet located adjacent to the kitchen. The laundry closet contained a washer and dryer and properly secured cabinets containing laundry chemicals. LPA observed a fire extinguisher mounted in the kitchen to be fully charged and purchased on 09/24/2024. Continued on LIC 809C. COMMON AREAS : This includes the dining area, living room, hallway, office. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contains a dining table with adequate seating for resident use. The living room was observed to be clean with adequate seating for resident use. LPA observed the living room to contain an adequately screened fireplace and activities for resident use. LPA observed one (1) hallway closet to contain non-perishable foods and emergency water supplies. One (1) additional hallway closet was observed to contain extra care supplies. LPA observed one (1) railing support in the hallway to be detached from the railing. The office was observed to be locked and inaccessible to clients in care. At 11:23 AM LPA observed the sliding door screen to contain a tear in the screen material. The facility’s fire and carbon monoxide alarms were tested at 11:33 AM. The facility’s fire alarm functioned properly at the time of the visit. At 11:33 AM LPA observed the facility’s carbon monoxide alarm to fail to function during the test. The facility backup Administrator replaced the carbon monoxide alarm at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. BEDROOMS : There are seven (7) bedrooms in the facility; six (6) are single occupancy resident rooms and one (1) is a staff room. LPA and facility staff toured all six (6) resident bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. At 11:26 AM LPA observed bedroom #1’s sliding screen door to contain a tear in the screen material. BATHROOMS : There are three (3) bathrooms at the facility. Two (2) bathrooms are designated as shared resident bathrooms and one (1) bathroom is designated as a staff bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 141.4 and 163.6 degrees Fahrenheit, which is outside of the range required by regulation. OUTDOOR SPACE: The facility has three (3) emergency exit gates. Two (2) are located in the front yard and one (1) is located in the backyard; LPA observed clear passageways for emergency exit use. The facility has adequate seating outdoors for resident use. At 11:24 PM LPA observed the facility’s backyard to be missing adequate shade for the seating area. LPA observed all rails to be appropriately secured at the time of the visit. Continued on LIC 809C. GARAGE: LPA observed the garage to be locked and inaccessible to clients in care. The garage was observed to contain cleaning supplies and extra care supplies, household tools, and chemicals. RECORD REVIEW: Record review began at 11:40 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Six (6) staff files were reviewed. One (1) staff file was observed to be missing the required LIC 501 Personnel Record sheet and LIC 508 Out-of-state disclosure sheet. One (1) staff file was observed to be missing the LIC 503 Health screening report – facility personnel and a negative TB test. One (1) file for a staff member, who was working at the time of the inspection, was not located at the facility. LPA observed all caregiver staff members to be missing adequate trainings conducted within the last 12 months. Four (4) resident files were reviewed. One (1) resident’s physician report was observed to not be updated following a change in condition. Additionally, the resident's file was observed to be missing a negative TB test. MEDICATION REVIEW: Medication review began at 01:50 PM. Medications for four (4) of four (4) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 01/10/2025. LPA observed the facility to be utilizing an out-of-date LIC 610E, Emergency Disaster Plan for Residential Care Facilities for The Elderly. The infection control plan is reviewed/updated annually by the facility’s Administrator. INTERVIEWS: LPA interviewed two (2) residents. The residents interviewed stated that the staff treat them well and are attentive to their needs. LPA interviewed two (2) staff members. Both staff members interviewed were knowledgeable on the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. Continued on LIC 809C. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.