Routine inspection·June 18, 2024

Licensing Program Analysts (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Maria Jacobo, administrator for the facility, and was granted entrance. There are seventy-six (76) total residents residing in the facility, six (6) of which are non-ambulatory and seventy (70) of which are ambulatory. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control practices and Personal Protective Equipment (PPEs) were observed. · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a two-story building located in a residential neighborhood. It is licensed for a capacity of sixty-four (64) non-ambulatory residents and ninety-six (96) ambulatory residents, and the second floor of the facility is approved only for ambulatory residents. The facility consists of a kitchen, a dining room, an activity room, a television room, eighty resident bedrooms, a public resident restroom, and two outdoor patio areas that contain a shaded area. LPA checked seven (7) resident bedrooms and found that they had all the required furnishings and fixtures, and LPA also measured the hot water temperature in the public bathroom, along with the bathrooms of resident rooms #10, 11, 23, 27, 37, 55, 58, 61, 63, and 70, all of which fell within the required range of 105 – 120 Degrees Fahrenheit. The facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has multiple fully charged fire extinguisher located throughout the facility. · Water temperature readings were within the required range of 105 - 120 degrees Fahrenheit. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a capacity of sixty-four (64) non-ambulatory residents and ninety-six (96) ambulatory residents, and the second floor of the facility is approved only for ambulatory residents. · Care and supervision to meet the clients’ needs was observed. Staffing: · Twenty-one (21) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Seven (7) staff files were reviewed for criminal background clearance and training. · Seven (7) staff records reviewed have health/TB screenings. · The administrator’s certificate expires on 11/2/2025. Resident Rights/Information: · Physician orders were reviewed for seven (7) resident files. · Medications were also reviewed for seven (7) residents. Resident Records/Incident Reports: · Seven (7) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. · Staff training was on file. Disaster Preparedness: · Emergency and Disaster Plan was publicly posted and found within the facility. · The last emergency and disaster drill was conducted on 2/14/2024, which is not within the requirement that the drill be conducted quarterly. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs: · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided.