Routine inspection·February 3, 2025

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 2/3/2025 and was greeted by Administrator Michael Tanada. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms inspected contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. Facility has video surveillance inside common areas. Food Service: LPA Ramirez observed sufficient supply of non-perishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed an activities schedule for the month of February 2025 posted. The facility does not have a full-time staff member, responsible to organize, conduct and evaluate planned activities. LPA Ramirez will issue a Type B deficiency based on this observation. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 1/3/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry. See 809-C Residents with Special Needs : No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication room and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for John Michael Tanada expires 9/22/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for fifty (50) ambulatory and thirty (30) non-ambulatories. Rooms #1, thru #19, #24, #30 and #38 are cleared for non-ambulatory residents. This facility may retain no more than eight (8) hospice residents. There were zero (0) residents under hospice care during inspection. Resident Records/Incident Reports: LPA reviewed resident records for four (4) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. One (1) deficiency was observed and cited during this annual inspection. Exit interview was conducted. A copy of this report, 809-D, LIC 9102, and appeals rights was provided via email.