Routine inspection (multi-day)·May 23, 2025

Licensing Program Analyst (LPA) Quoc Huynh arrived unannounced at 10:15AM for a Case Management Annual Continuation visit. Executive Director (ED) Lito Vitug arrived at 10:57AM, met with LPA Huynh and LPA explained the reason for the visit. Entrance interview conducted. At 11:10AM, the LPA and ED briefly toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. At this time, no immediate health and safety hazards were observed. MEDICATION: Medication review began at 11:16AM. The LPA reviewed medications for four (4) residents. Medications are maintained locked inaccessible to residents in an attached room behind the concierge desk located on the first floor. Four (4) out of four (4) resident medications reviewed were documented and stored in compliance with regulation at this time. Report Continued on LIC 809-C PLAN OF OPERATION/INFECTION CONTROL: LPA reviewed the facility's Plan of Operation and Infection Control Plan at 11:49AM and is in compliance with regulation. The facility maintains a current and written definitive Plan of Operation that includes all required topics per regulation. LPA observed the facility’s Infection Control was reviewed and signed recently. RECORDS: Resident records were reviewed at 12:27PM. The LPA reviewed five (5) resident records for, but not limited to: admissions agreements, medical assessments, and appraisals. LPA observed one (1) out of five (5) residents did not have a TB test completed. Personnel records were reviewed at 12:56PM. The LPA reviewed six (6) personnel records, but not limited to: job application, health assessments, TB results, criminal record statements and clearances, first aid/CPR certification, and staff trainings. Two (2) out of six (6) staff did not have a completed health screening signed by a physician, and one (1) out of six (6) staff did not have a TB test. Documents obtained: Infection Control Plan. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. A copy of today's report and appeal rights were reviewed and provided.