Routine inspection·May 3, 2024

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today. The last annual conducted at this facility was on 05/25/2023. Upon LPA arrival, there were three (3) staff and six (6) residents present. LPA was greeted at the door by staff and the reason for the visit was explained. The Administrator, Emiliano Siapno arrived shortly after. Entrance interview. At 8:55 a.m., the LPA along with the Administrator 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. KITCHEN: The LPA inspected the kitchen/food service area at 9:00 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. The knives and sharps are stored in a locked drawer inaccessible to residents in care. At 9:01 a.m., the hot water temperature was measured in the kitchen sink, and it measured 114 degrees Fahrenheit. COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 9:13 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed to be in compliance and newly purchased on 08/07/2023. The LPA observed required postings throughout the common space. Continued on LIC 809C... Continued from LIC 809... There is a working telephone on premises. There is a separate laundry room with a washer and dryer that was observed locked and inaccessible at the time of the visit. The facility has a sufficient amount of emergency food and water which was observed to be in good condition. The LPA observed a sufficient supply of Personal Protection Equipment (PPE). BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There was one (1) gate that self-latches. No bodies of water were noted at the time of the visit. BEDROOMS: There are four (4) resident bedrooms. One (1) bedroom is for single occupancy, and three (3) bedrooms are double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There are three (3) resident restrooms. The first restroom is located in the hallway, the second restroom is located inside bedroom #6, and third restroom is a jack and jill located between bedrooms #1 and #2. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in all bathrooms. First bathroom measured 112.8 degrees Fahrenheit at 8:57 a.m., the second bathroom measured 113.2 degrees Fahrenheit at 8:59 a.m., and the third bathroom measured 114.1 degrees Fahrenheit at 9:10 a.m. RECORDS: Records review began at 9:28 a.m.; six (6) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. Continued on LIC 809C... Continued from LIC 809C... Three (3) personnel records and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were complete. The last emergency disaster drill took place on 03/08/2024. During today’s visit, the LPA obtained copies of the following documents: Personnel Report – LIC 500, Client Roster – LIC 9020, Emergency Disaster Plan – LIC 610E, and current Limited Liability Insurance. The LPA conducted an interview with one (1) staff member during the inspection. MEDICATIONS: Medications review began at approximately 12:30 p.m.; medications are centrally stored in a locked cabinet adjacent to the kitchen. At 12:44 p.m., medications review revealed that Resident #1’s (R1’s) medications Vitamin D3 and Coenzyme Q-10 both filled on 03/22/2024 were started on 05/01/2024; however, were not documented on the Centrally Stored Medication and Destruction Record (CSMDR). Staff documented medications on CSMDR at the time of the visit. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Exit interview conducted. A copy of the report and appeal rights were provided.