Routine inspection·September 10, 2024

Licensing Program Analyst(s) (LPA) Jose Villalobos and Luis De Leon conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with House Manager Nick Baez and the purpose of the visit was explained. The facility is licensed to serve adults age 60 and above. Fire clearance for four (4) ambulatory and two (2) non-ambulatory. The facility is licensed as a 4C home vendored by San Gabriel Pomona Regional Center. The following CARE tools domains were utilized during the inspection. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Visitors are no longer screened for COVID-19 or required to sign in. The facility has an Infection Control Plan and COVID-19 Mitigation Plan. Physical Plant/Environment Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: Living room, kitchen, dining area, four clients bedrooms, two clients bathrooms and attached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Water temperatures measured within Title 22 requirements. The facility has one (1) fully charged fire extinguisher. Operational Requirements: Facility has a fire clearance for four (4) ambulatory and two (2) non-ambulatory residents. Currently three (3) residents are ambulatory and one (1) resident is non-ambulatory. The facility is vendored by San Gabriel Pomona Regional Center. Facility was unable to provide LPA proof of required Liability Insurance. Facility has a surety bond in place. Incident Medical and Dental: LPA reviewed medications for four (4) Residents. 30-day supply of resident medications were observed. The medications are centrally stored in locked cabinet. Centrally Stored Records for medications are kept. Medication stored matches the medication record for each resident. Staffing: Sufficient caregiver staff provide care and supervision to the residents. Continued on LIC 809-C Personnel Records/Staff Training: Administrator certificate is currently pending renewal from the department. Personnel files were reviewed. LPA reviewed a total of three (3) Staff files. LPA observed required documents for each. Proof of staff training was reviewed. 1st Aid/CPR records are current. Resident Records/Incident Reports: A total of four (4) resident files were reviewed containing admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment, and emergency information forms were observed. Appraisals on file are over a year old for each resident. Residents Right-Information : RCFE complaint poster and Personal rights were observed to be posted. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Cleaning supplies are locked separately from any food items. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place and was posted today. Facility to update to latest version of the form. Residents with Special Health Needs: No residents receive home health services. No postural supports observed. (1) resident with half bed rails. No residents are on hospice. No residents have prohibited health conditions. No residents have restricted health conditions. Per title 22 regulations, a deficiency is being cited on todays visit. Please see attached 809-D page. Exit Interview conducted. Appeal rights discussed. A copy of this report and the appeal rights were provided.