Routine inspection·September 12, 2022

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Gladys Pervez who assisted with visit. The facility is licensed to serve one (1) bedridden and five (5) non-ambulatory residents (ages 60 and above). The facility has an approved Hospice Waiver for five (5) residents. Currently, there are six (6) residents in placement including three (3) hospice residents. Annual licensing fees are current. Administrator certificate is current and the expiration date is 02/08/23. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. LPA observed the facility to have four (4) resident bedrooms, two (2) bathrooms, living room, dining room, kitchen, garage equipped with a laundry area and an indoor/outdoor activity area. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was 119.0 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. Last fire drill was conducted on 8/30/22. Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers’ last service is 3/10/22 and are fully charged. (-continued in LIC 809C-) The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored in a locked cabinet in med room and inaccessible to residents. Resident records are stored and locked in med room, inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates. No deficiencies were observed and cited per California Code of Regulations, Title 22. An exit interview was conducted. This report was discussed with Administrator, Gladys Pervez's signature on this form confirmed receipt of these documents. A copy of LIC 809s report was provided.