Routine inspection·October 3, 2024

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:18AM. LPA met with Administrator Jennifer Fernandez and reason for the visit was explained. Entrance interview conducted. Beginning at 9:20AM, the LPA, along with the 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: KITCHEN: LPA inspected the kitchen at 9:20AM. Knives and sharps are stored in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of 2 (two) days perishable and 7 (seven) days non-perishable food and an emergency water supply. Food was stored at appropriate temperatures. At 09:21AM, LPA observed three (3) tomatoes, two (2) peppers, two (2) packages of okra, and two (2) zucchini that were spoiled. Staff discarded all items immediately. BEDROOMS : The facility consists of seven (7) total bedrooms, six (6) are designated for single-resident use and 1 (one) is designated for staff use and is kept locked. Bedroom #5 is temporarily utilized as a staff room for a maintenance worker for the past month. Administrator anticipates that Bedroom #5 will no longer be used as a staff room in the next 2-3 weeks. Bedrooms #1, #3, #4, #5, and #6 have exits to the exterior. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, closet space, and sufficient lighting. At 09:34AM, LPA observed Resident #1 (R1) in Bedroom #3. R1 is bedridden and the facility has a fire clearance for bedridden residents only for Bedroom #1. Bedroom #3 is cleared for non-ambulatory. Bedroom #1 is currently empty. Administrator stated they will move R1 from Bedroom #3 to Bedroom #1 as it is cleared for bedridden. Report Continued on LIC 809-C BATHROOMS : There are three (3) full bathrooms one in the main hallway and two Jack and Jill's (between room #4 and staff room, and room #5 and #6) designated for, residents, staff and guests. The showers are equipped with nonskid mats. Grab bars were observed in the bathrooms. LPA measured water temperatures in the all three (3) bathrooms to be between 119.2 – 125.4 degrees Fahrenheit between 09:27AM – 09:39AM. Administrator lowered the water temperature during the visit and provided water temperature logs. LPA remeasured water temperatures to be between 121.1 – 122.3 degrees Fahrenheit between 11:36AM – 11:44AM. COMMON AREAS : This includes the living room, family room, and dining room. LPA observed common areas to be clean and properly furnished at the time of the visit. Facility is maintained at a comfortable temperature of 72 degrees Fahrenheit. The facility smoke alarm system is hard wired. The carbon monoxide detector in the hallway was tested at 09:32AM and the smoke detectors and three (3) fire doors were tested at 09:46AM; all were operable at the time of the visit. There is one (1) fire extinguisher by the kitchen which was fully charged and last serviced on 08/28/2024. There is a functioning telephone on the premises. Emergency exiting plans/sketch, emergency telephone numbers, license, and personal rights are posted on the entry way wall. LPA observed auditory exit alarms by all exit doors in the common areas and bedrooms which were functional and operating. OUTDOOR SPACE: The backyard has a covered patio area with furniture including a table and chairs. There were no bodies of water on the premises. Only one (1) pathway is used as an emergency exit which was free of obstruction and was equipped with a self-closing and self-latching door. GARAGE/LAUNDRY: At 09:44AM, LPA observed the locked garage. The garage can be accessed from the side of the property and from the dining area. The garage contains additional supplies, a washer and dryer, detergents, and an additional refrigerator/freezer with a lockbox for storing refrigerated medication. 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 plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 08/14/2024. Report Continued on LIC 809-C RECORD REVIEW: LPA began record review at 10:10AM. LPA reviewed one (1) out of one (1) resident files and three (3) out of six (6) personnel files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Resident and personnel files were complete and had no missing documents. At 10:25AM, LPA observed Staff #1 (S1) without a criminal record clearance transfer. Administrator contacted the licensee, Joseph Jose, who immediately associated S1 to the facility. Administrator confirmed that S1 has been at the facility for one month and licensee confirmed to LPA telephonically that S1 was associated to the licensee’s other facilities. MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the dining room. LPA began medication review at 09:50AM and medications for one (1) resident was observed. All medications reviewed were stored and documented per regulation. INTERVIEWS: During today's visit, LPA interviewed two (2) staff and attempted an interview with one (1) resident. During today's visit, LPA obtained a copy of the facility's liability insurance. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty was issued in the amount of $1000. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.