Routine inspection·January 23, 2024

Licensing Program Analysts (LPAs) Valeria Conway and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 11:43AM. LPAs initially met with facility staff. Administrator was contacted via telephone and arrived at the facility at 12:20PM. Entrance interview conducted. Beginning at 12:25PM, the LPAs, along with Administrator 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: Fire extinguisher is fully charged and last serviced on 03/27/2023. Hardwired smoke detectors were tested at 04:34PM, separate carbon monoxide detector was tested at 04:35PM and all were functional at the time of the visit. Fire pulls were tested during January 2023 fire inspection. No fire clearance concerns were observed during today's visit. BEDROOMS : There are six (6) total bedrooms in the facility; five (5) bedrooms are designated for resident use and one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. KITCHEN : The LPAs observed the kitchen. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Knives were locked in a kitchen drawer. At 12:35PM, LPAs observed cockroaches around the refrigerator, inside kitchen cabinets, and on the kitchen floor. COMMON AREAS : This includes the living room and dining room areas. LPA observed common area to be properly furnished at the time of the visit. A fireplace was noted in the living room to be covered and Report Continued on LIC 809-C inaccessible to residents in care. At 12:00PM, LPAs observed a cockroach on the entry way table and a dead cockroach on the windowsill. Laundry area was observed in the hallway, with locked chemical storage. BATHROOMS : There are two (2) bathrooms for resident use. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured and was in compliance with regulation. LPAs observed a dead insect taped to the restroom wall in the back common restroom. GARAGE : Detached garage was observed locked and extra food, supplies, and emergency food and water, and chemical storage. LPAs observed expired macaroni and cheese in the outdoor food storage area. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There was a fountain observed on the back patio, which was inoperable, but did contain standing water from the recent rain. LPAs advised Administrator to remove standing water and ensure no further water is deposited in the fountain. At 12:58PM, LPAs observed both outdoor gates to not be self-closing or self-latching. RECORD REVIEW: Resident records were reviewed for documents including, but not limited to: physician's report, needs and service appraisal, and personal rights. Two (2) of five (5) resident files observed contained an Admission Agreement for the closed facility previously located at this address. All remaining files observed were in compliance with regulation. Staff files were not reviewed during today's visit. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs reviewed the facility's emergency disaster plan. Last emergency drill was conducted on 01/11/2023. Emergency disaster plan was observed to be complete and updated annually, as required. Infection control plan was not reviewed during today's visit. MEDICATION REVIEW: Not reviewed during today's visit. Report Continued on LIC 809-C INTERVIEWS: Interviews were not conducted during today's visit. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.