Routine inspection·July 5, 2023

Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility to conduct a required annual visit. The LPA met with Facility Administrator Susan Caldwell at approximately 9:40 a.m. and explained the reason for the visit. The LPA along with Administrator Caldwell toured the physical plant areas inside and outside at approximately 10:20 a.m., with Administrator Susan Caldwell., to ensure that there are no health and safety hazards. BEDROOMS: There are (5) bedrooms designated for resident use. Bedroom #1 is single occupancy with no private bathroom and an exit to the exterior. Bedroom #2 is single occupancy with no private bathroom and no exit to the exterior. Bedroom #3 is a shared room containing two beds, two closet spaces with outdoor access and a shared bathroom. Bedroom #4 is single occupancy with a private bathroom and a direct exit to the exterior. Bedroom #5 is single occupancy with a private bathroom and a direct exit to the exterior. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage. BATHROOMS : Resident bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. The bathrooms hot water measured between 108.5 degrees Fahrenheit and 117.0 degrees Fahrenheit. KITCHEN : Kitchen knives are stored in a locked cabinet in the kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. Continued on LIC 809-C There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet. No flies or other vermin were observed. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. The LPA observed the required postings in the common hallway. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system and carbon monoxide detector was tested and operated normally at the time of visit. Medications were observed to be locked in a cabinet in the kitchen and contained at least 30 days of worth of medication. The laundry room is located in a backroom by the kitchen. GARAGE: The LPA toured the detached garage which is used as the facility office. The garage was free of obstructions and the cabinets were properly secured at the time of the visit. BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Furniture was observed to be in good repair. There were no bodies of water noted. The LPA observed a locked shed in the backyard which was inaccessible to residents at the time of the visit. INFECTION CONTROL: During today’s visit, LPA Ascencio spoke with Administrator regarding the facility’s infection control practices. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The LPA noted that the facility is allowing visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate. Continued on LIC 809 - C The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties: - Starting at 11:35 a.m., during kitchen tour, LPA observed bleach in an unlocked kitchen cabinet under the sink accessible to residents. Staff secured items during tour. - Starting at 12:15 p.m., during staff file review, LPA observed Staff #1 (S1) not associated to facility. LPA spoke to Administrator and stated they should have been associated. LPA check on Guardian and did not observe S1 associated to the facility. Administrator submitted documentation to CCL. An immediate $500.00 civil penalty was assessed. - Starting at 12:20 p.m., during staff file review, LPA observed two (2) staff members not having their initial 40-hours of required training. - Starting at 3:02 p.m., during resident file review, LPA observed Resident #1 (R1) not have a current LIC 602 Physician's Report for 2023. Additionally, 6 out of 6 residents did not have a signed Appraisal/Needs and Service Plan signed by the representative. Due to time restrain, the LPA will continue the required annual at a later time. Exit interview conducted and a copy of the report and appeal rights were provided.