Routine inspection·February 26, 2025

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:06 AM. LPA met with facility Administrator Jose Guevarra Jr. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:10 AM, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN : The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed two (2) fire extinguishers located in the kitchen. One (1) was observed to be empty and one (1) was observed to be full and purchased on 10/10/2024. LPA observed adequate emergency food and water supplies stored in the kitchen. Continued on LIC 809C. COMMON AREAS : This includes the living room, hallway, laundry room, and dining area. LPA observed the dining area to be clean and properly furnished at the time of the visit. The dining area contains a dining table with adequate seating for resident use. The living room was observed to be clean and in good repair. The living room contained activities and adequate seating for resident use. LPA observed the living room to contain an adequately screened fireplace. LPA observed a properly secured hallway closet to contain the facility’s complete first aid kit, resident medications, and facility files. An additional hallway closet was observed to contain resident clothing. LPA observed the laundry room to be locked and inaccessible to clients in care. The laundry room contained a washer and dryer, laundry chemicals, cleaning chemicals, and extra linens. LPA observed cameras located throughout the common areas of the facility, LPA confirmed with the facility Administrator that audio is not recorded. The facility’s combination fire and carbon monoxide alarms were tested at 02:56 PM and were functional at the time of the visit. BEDROOMS : There are six (6) bedrooms in the facility; two (2) are dual occupancy resident rooms, one (1) is a single occupancy resident room, and three (3) are staff rooms. LPA toured all six (6) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #4 and #5 were observed to contain direct exits to the outside of the facility. BATHROOMS : There are three (3) bathrooms at the facility. One (1) bathroom is designated as private resident bathroom, and two (2) bathrooms are designated as shared resident bathrooms. All resident bathrooms were observed to be relatively clean and in relatively good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 136.8 and 143.4 degrees Fahrenheit, which is outside of the range required by regulation. At 09:31 AM LPA observed the private resident bathroom attached to bedroom #5 to contain a moldy shower curtain. OUTDOOR SPACE: The facility has two (2) emergency exit gates. One (1) is located in the front yard and one (1) is located in the backyard; LPA observed clear passageways for emergency exit use. The gate on the north side of the facility’s backyard is not an emergency exit gate and leads to the yard of an attached ADU. The facility has adequate shaded seating outdoors for resident use. LPA observed one (1) secured storage shed in the backyard of the facility. At 09:34 AM LPA observed an unsecured gardening trowel/hoe combination tool unsecured in the backyard. Continued on LIC 809C. RECORD REVIEW: Record review began at 10:05 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. three (3) staff files were reviewed. One (1) staff file for a staff member currently at the facility was observed to be missing from the facility’s records. One (1) additional staff file was observed to be missing their LIC 503 – Health screening form, a negative TB test, and up to date trainings. Four (4) resident files were reviewed. Two (2) resident files were observed to be missing a negative Tuberculosis (TB) test. MEDICATION REVIEW: Medication review began at 11:55 AM. Medications for four (4) of four (4) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 03/14/2024 which is outside of the required timeframe. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. INTERVIEWS: LPA interviewed two (2) residents. One (1) resident stated that they wish the facility showered residents more frequently than once a week. Both resident’s interviewed stated that activities are not currently offered at the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their role and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. The staff member interviewed stated that they last received their annual trainings between two (2) to three (3) years ago. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.