Routine inspection·September 20, 2021

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. Upon arriving at the facility, LPA met with Mariciel Gamboa (Administrator) and explained the purpose of the visit. The facility has a capacity of six (6) residents. It is licensed to serve elderly residents age 60 and above, and approved for six (6) non ambulatory residents. Facility may retain four (4) hospice residents. Facility will have 24 hour awake staff. Current, no resident is residing at the facility. During the visit, the infection control domain tool was used, a tour of the facility was conducted, and food supply was reviewed. Since no resident residing at the facility, no medication was reviewed. The facility is located in a residential area. A physical tour was conducted. The facility is a single-story house includes: living room, dining area, attached garage/storage, kitchen, pantry, TV room, three (3) resident bedrooms, two (2) bathrooms. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 107.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies. There are no pools and bodies of water on the premises. There are no firearms on the premises. Facility maintains a comfortable temperature for residents. Sufficient supply of perishable and nonperishable foods were observed. Smoke detectors and carbon monoxide detectors are operable. Smoke detectors in the hallway and bedrooms are hard wired. New fire extinguishers were purchased on August 2021 and are fully charged. (-continued in LIC 809C-) The first aid kit is fully stocked. All mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked storage room and inaccessible to residents. Resident records are stored in a locked storage room and inaccessible to residents. Facility was renovated. No change on capacity and ambulatory status. On the initial application, there was a walk-in closet in the master room and a laundry room. A wall between a walk-in closet and laundry room was removed. That space was turned into a staff lounge. City of Arcadia granted the permit of the renovation. City inspector will visit the facility for an inspection on 9/21/21. Administrator agreed of not admitting resident until the facility is cleared and has a fire clearance. Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D. An exit interview was conducted. This report is discussed and provided to facility Administrator, whose signature on this form confirm receipt of these documents. A copy of appeal rights was provided