Routine inspection·December 15, 2023

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Administrator, Liubov Shevtsova, and explained the purpose for the visit. During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (4) resident medications, (4) resident files, (3) staff files, and conducted interviews with (2) staff, and attempted interviews with (4) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (5) non-ambulatory residents and (1) bedridden resident. It has an approved Dementia Care Plan and a Hospice Waiver approved for (3) residents. There is currently (1) resident receiving hospice services. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file. LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are 1 full and one half bathrooms in the home- both equipped with required grab bars and non-skid mat for the shower. The hot water was tested and measured at 112*F, which is in compliance. Food supplies was observed and was sufficient as required. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The last fire drill was conducted on 11/20/2023. Auditory devices were observed at all entrances/exits of the home. (4) of (4) resident files were reviewed and observed to be missing Functional Capabilities Assessments and Needs and Services Plans. (1) of (4) resident files were observed to be missing an updated medical assessment/Physician's Report, as required annually due to their cognitive impairment. (3) staff files were reviewed and had all the required documentation. (4) resident medications were reviewed and were observed to be documented properly and given as prescribed. Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the attached LIC9099-D page. Exit interview was conducted and a copy of this report and appeal rights were provided.