Routine inspection·September 16, 2024

Licensing Program Analysts (LPAs) Mariana Agban, Angelica Segovia and Evelin Rios conducted an Annual Required visit for this facility. LPAs arrived at the facility and were granted access by Staff #1 (S1). S1 contacted the administrator designee, Stephanie Domingo. LPA Rios met with the administrator shortly after and explained the reason for the visit. The facility is licensed for a total capacity of six (6) non ambulatory residents of which one may be bedridden. Facility has a hospice waiver for six (6). At approximately 11:40 a.m. LPAs and staff #2 (S) tour the physical plant of the facility inside and out and the following was observed: Bedrooms: There are six (6) total bedrooms, for private use. Bedrooms were observed to be properly furnished with appropriate furniture, bedding and sufficient lighting. Auditory alarms were observed on Exit doors and were not functioning properly in four (4) doors; two (2) emergency exit doors in two bedrooms and two (2) sliding glass doors in the living area and bedroom area. Bathrooms: There are two (2) bathrooms. Bathrooms were properly supplied with toilet paper, paper towels, hand soap, nonskid matts and grab bars. LPA observed night-lights in the hallway leading to the bathrooms. Hot water temperature was measured at 2:45 p.m. and read between 117 and 120 degrees Fahrenheit within regulation. Common Areas : These included the living rooms and dining area. The common areas were clean and clear of clutter, properly furnished. The dining room table is large enough to sit the capacity of the facility. Seating such as couches where in good repair and sit the capacity of the facility. A fireplace was observed off and secured with a screen. LPA observed two (2) telephones accessible to residents. (Continued on LIC809-C) Laundry and Staff Rooms: The laundry room is located in the hallway by the residents' rooms and leads to the staff rooms. Laundry room is accessible to residents. Detergents and cleaning supplies were observed locked in the laundry room cabinet. Door from laundry room to staff rooms is maintained locked. Surrounding Grounds : Entry/exits were free of obstructions. The outdoor patio offers shade and there was furniture appropriate for outdoor use. The outdoor area was free of hazards. There is no bodies of water on property. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility; properly stored. Knives and sharps were stored in a locked kitchen cabinet. There are smoke detectors that are hard wired and interconnected. Administrator tested detectors at 12:21 p.m. and LPA observed detectors properly functioning. LPA observed fire doors. There are two fire extinguishers both observed fully charged. The carbon monoxide detector was not functioning at time of visit. Resident and Staff Files : At 12:30 p.m. LPAs reviewed resident and staff files. LPAs conducted a file review of four (4) out of four (4) resident records to insure compliance of licensing forms. LPA also conducted a file review of two (2) staff records to insure forms and training are up to date and in compliance with licensing forms. Medications : At 12:50 p.m. LPA reviewed Medication and Medication Records. LPA observed medications locked in a hallway closet. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR). Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, there were deficiencies observed during the visit (refer to LIC809-D). Exit Interview Conducted and a Copy of the Report Issued.