Routine inspection·July 19, 2024

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:01AM. LPA met with Licensee/Administrator Susan Caldwell. Entrance interview conducted. Beginning at 9:03AM, the LPA, along with Licensee/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 extinguishers are fully charged and recently serviced on 04/02/2024. Hardwired combination smoke and carbon monoxide detectors were tested at 09:43AM and were not operating, however, staff changed batteries at 9:46AM and all were functional at the time of the visit after staff changed the battery. LPA observed exit alarms by doors but were not able to be turned on. BEDROOMS : There are 5 (five) total bedrooms in the facility; 4 (four) are designated as private resident rooms and 1 (one) is a shared resident room. 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 linens; 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. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report Continued on LIC 809-C BATHROOMS : There are 5 (five) total bathrooms. 4 (four) bathrooms are for resident use and 1 (one) is kept locked for staff use and medication storage. Knives and sharps are stored locked in staff bathroom by the kitchen. Restrooms were observed to contain nonskid surfaces. Grab bars by the showers and toilets were observed in the bathrooms. The water temperature was measured in 2 (two) resident bathrooms and measured between 111.1 and 116.6 degrees Fahrenheit, which is within the required range. LPA observed a storage space closet in hallway containing clean linens for resident use. COMMON AREAS : This includes the living room, dining room, den, and sitting room areas. LPA observed common areas to be clean and properly furnished at the time of the visit. LPA observed surveillance cameras in common room which do not record audio. OUTDOOR SPACE: The backyard has covered patio areas with patio furniture including tables and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. LPA observed a guest house in the backyard where Licensee/Administrator lives. LPA observed the front gate to be unlocked and self-latching, as is required. KITCHEN : Kitchen was observed to be clean. 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. Cleaning supplies, washer and dryer, and detergents are located in the locked laundry room adjacent to the kitchen. At 9:12AM, LPA observed 6 (six) cans of expired garbanzo beans dating between April to May 2024 in the hallway pantry. At 9:18AM, LPA observed a bag of expired lettuce dated 07/09/2024 and mayonnaise dated 07/14/2024 in the kitchen refrigerator. Staff discarded all expired items immediately. GARAGE: A1:54PM, LPA toured the detached garage which has been converted to the facility office. The garage was free of obstructions. 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 not conducted quarterly, however, Licensee/Administrator conducted a fire drill at 11:50AM during the time of the visit. Report Continued on LIC 809-C RECORD REVIEW: LPA began record review at 9:53AM. LPA reviewed 5 (five) out of 5 (five) resident files and 5 (five) staff 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. 3 (three) out of 5 (five) resident files and 4 (four) out of 5 (five) staff files were missing documents. MEDICATION REVIEW: Medications for 2 (two) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. During medication review around 12PM, LPA observed alterations to medication labels, which is not in compliance with federal regulations. INTERVIEWS: During today's visit, LPAs interviewed 1 (one) staff and 2 (two) residents. 1 (one) staff member was not associated with the facility and left premises, but Licensee/Administrator was able to associate staff during the time of the visit. 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 were issued in the amount of $500. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.