Routine inspection·March 18, 2023

Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA Flores met with Jeffrey Yang Assistant Administrator and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory residents age 60 and above. Facility has a dementia waiver and are allowed to care for 1 resident on hospice at any one time. The facility is a single-story home, located in a residential area. It consist of; an administrator office room, kitchen, living room, family room, dining room, 6 resident bedrooms, 1 staff bedroom, 3 resident bathrooms, 1 staff bathroom, a detached garage, a front yard and backyard. LPA Flores conducted a tour of the facility with Fresmida Vizcarra Caregiver and observed the following: Facility is in clean and good repair indoors and outdoors. Kitchen is clean, sharps were locked in drawer next to dishwasher. Sufficient food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. (6) Resident's bedrooms were observed with sufficient lighting, furniture, and bedding supplies. (3) Resident's bathrooms were observed in working condition with grab bars, skid mats, and water temperature was tested between 112.7 - 113.7 which is within the required 105-120 degrees F. Dining room, living room, and family room were observed with sufficient sitting area. Smoke/Carbon monoxide detectors were tested and in working condition. Backyard was observed with covered sitting area, a 5ft fence was observed around the pool. Cleaning supplies are maintain in the garage inaccessible to the residents. Complaint poster is posted on kitchen board printed in 8x11 size poster which is not the required 20x26 size. Last emergency drill was conducted on 8/1/21. Per Title 22 drills should be conducted at least quarterly. LPA Flores reviewed medication and files for 5 residents. Resident #4(R4) last physician's report was dated 3/20/19, annual assessment is required. Resident #1(R1) has a request for special diet. Per staff there are no special diets instructions currently being followed. Each resident file reviewed did not have an admission agreement available in the resident's files at the time of the visit. Staff files were reviewed for (5) staff. File for staff #5(S5) was not available at the time of review. (CONTINUED LIC 809C) Annual training for staff was not available during the visit. An administrator certificate was reviewed for Jeffrey Yang #6009748740 exp: 12/1/23. Deficiencies have been noted on 809D per Title 22 Regulations. Exit interview was conducted with Fresmida Vizcarra Caregiver. Report, and LIC 809D were email for signature due to technical issues. A copy of report, LIC 809D, and appeal rights were email.