Routine inspection·November 1, 2024

An unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan on 11/01/2024 at 9:30 am. Upon arrival LPA met with Marasikova Damira, Caregiver, who granted access to the facility. LPA explained the reason for the visit. Shortly after the Facility Administrator, Marine Grigoryan arrived. LPA was informed that the facility currently has five (5) residents, of which two (2) residents are non-ambulatory. One (1) resident is on hospice and two (2) residents are receiving Home Health. Facility has waiver for 4 hospice residents. Resident Files: At 10:15am team conducted resident and staff records review. The following was observed. Five (5) out of 5 resident files were incomplete. Files were missing signed and completed Admissions agreements, Physician’s reports, resident preplacement appraisals/resident reappraisal, List of personal property, ID Emergency Sheets. Resident appraisals that were in the file did not have services explained and were missing signatures from the resident, and or responsible party. Please see LIC858 included with this report. Hospice and Home Health files are missing and or incomplete missing care plan, admissions, notes. Staff Files: The following was observed. There are no completed personnel records for all six (6) staff members which include the administrator. All files were missing personnel records (LIC501), Health Screening/TB results (LIC503), Documented medications and general training not completed. Please see LIC859 included with this report. With the assistance of the Licensee/administrator, a tour of the physical plant was initiated at approximately 11:00am and the following was observed: Continue on LIC809-C KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPA found sufficient amount of two (2) days of perishable and seven (7) days of non-perishable food; emergency food was also stored inside the kitchen cabinets. LPA checked no expired food was found. Unsealed food was properly stored with labeled dates on them. LPA observed dining ware to accommodate a maximum capacity of six (6) residents. Knives and sharps were stored locked inside the kitchen cabinet. Kitchen chemicals and toxins are stored in the separate locket cabinet. Laundry machines are also located in the kitchen next to the staff bathroom and are always under supervision. COMMON AREAS: The facility maintains a comfortable temperature at 72°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. LPA observed puzzles, books, balls, and board games to provide activities to residents in care. Living room has fireplace, which is properly fenced and not accessible to residents in care. Facility has land line, LPA checked its operational. MEDICATION: LPA observed medication, staff/resident files, and First Aid kept inside the locked cabinet located office area near the kitchen. LPA observed First-aid kit is complete and has new manual. Facility has Dementia Care Program. LPA observed each centrally stored prescription and PRN medication has been logged in the medications log. Proper medication dispensing instruction are followed and checked for contamination. All medications are properly labeled and checked for expiration dates. BEDROOMS: There are four (4) bedrooms designated for residents’ use. All bedrooms are furnished and well equipped with beds, nightstand, chair, dresser, bedding, and extra linen. Rooms were observed to have sufficient lighting and closet space. Facility has awake staff. Extra towels and linens were readily available and nicely stored in the linen closet located in the hallway. Facility has 2 staff for AM shift and 1 awake caregiver for PM shift. Continue on LIC809-C BATHROOMS: The facility has three (3) bathrooms, bathroom #1 is located next to the kitchen and it is designated for staff use, bathroom #2 is located in the hallway next to the bedrooms #1, and bathroom #3 is located inside bedroom #4. All bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 11:20am to be at 118°F degrees. All trash cans in bathrooms had fitted lids to protect from cross contamination. SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 12:00pm they were tested and observed to be operational. The facility has one (1) new fire extinguishers that was purchased on 11/1/2024. The fire extinguisher is located in the hallway next to the kitchen. SURROUNDING GROUNDS: The backyard of the facility has sufficient yard space and it’s fenced. Exit areas are free of obstructions and hazards, exit gates were unlocked and easily accessible. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. The facility has a swimming pool which is properly fenced and locked. There is no garage. The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. LPA collected LIC500, LIC9020, and Liability Insurance. Exit interview conducted and copy of this report signed and delivered.