Routine inspection·November 30, 2023

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Larry Ho and explained the reason for the visit. The facility is licensed to serve 3 ambulatory and 3 non-ambulatory residents age 60 and above. Non-ambulatory in ground bedrooms only. Facility is a two story residential home consists of (3) resident bedrooms, (1) staff/guest bathroom, 1 full bathroom, a living room, dining room, office area, kitchen, laundry area in the lower floor, (3) resident bedrooms, a sun room(storage), (1) resident bathroom, (1) staff bedroom and bathroom in the second floor. Backyard, a side garden that includes pergola table and chairs, detached garage for storage purposes, and a front yard. LPA toured the facility with Larry Ho and observed the following: Facility is in good repair indoor and outdoor, passages are clear of obstructions. Living room, office, front entrance, and dining are clean with sufficient furniture and activities. Bug killing spray was observed next to sofa by the entrance to the living room. Kitchen area is clean, pantry and refrigerator was observed with sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables. Staff medication container was observed in the kitchen's dining table, an apothecary cabinet was observed with residents medication to be dispensed accessible to the residents. Laundry area is clean, laundry detergent and bleach is accessible to the residents in a cabinet next to the washer. Each residents room has sufficient lighting, furniture, and bedding supplies. There are 2 residents on hospice with full bed rails with request per hospice on file, and 1 resident on home health care with a half bed rail request on file per physician. Each bathroom is clean and in working condition with grab bars and skid mats, water temperature was tested in each bathroom and tested between 107.7-109.5 degrees F. which is within the required 105-120 degrees F. Smoke/Carbon monoxide detectors were tested throughout the facility. Fire extinguishers were observed last checked on 3/13/21. Side yard is clean and has sitting area. No large bodies of water were observed. (CONTINUED ON LIC 809C) LPA reviewed medication for 3 clients, during medication review LPA observed an evening medication for resident #3 (R3) was finish and when asked if a refill was available staff explained the last pill was put on R3's ensure to be given to R3. During interviews a second staff confirm the medication is place in the R3's ensure. There is no physician's request to crush or hide medication in food or drinks. Facility does not have an emergency evacuation chair. There is no record of last emergency drill, and the Emergency Disaster plan although it was last reviewed on 7/27/23 does not meet the criteria for the most current Emergency Disaster plan version (12/21). LPA reviewed files for 3 residents and 5 staff. Administrator certificate was reviewed 6020655740 exp: 9/22/24. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Larry Ho and a copy of this report, LIC 809D, and appeal rights were provided.