Routine inspection·March 22, 2024

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by two caregivers (S1 and S2). LPA observed a third person and was informed it was a family member of the two caregivers. Upon entry at 9:15 am, LPA observed the delayed egress notification was not working at the front door. LPA stated the purpose of the visit was to conduct an annual inspection. The staff confirmed there are six residents. The facility is licensed for five non-ambulatory residents and one (1) bedridden resident. LPA Spaeth reviewed resident records at 10:00 am to 11:00 am. LPA Spaeth & caregiver toured the facility at 11:00 to 11:30 am. Living Room . - When entering the facility, the living room is located to the right and is a room with three walls. LPA observed a curtain was used as a door. LPA observed the room is used as a staff room and contained two twin beds. At 9:30 am, LPA observed staff member's medication was sitting out on a dresser. At 9:33 am, LPA observed the caregiver locked the medication in the resident's medication cabinet. Kitchen/Family Room - LPA Spaeth observed the kitchen and family room are combined. The facility contained a two day supply of perishable food and a seven day supply of non-perishable foods. The knives were locked in a kitchen cabinet. The cleaning solutions are securely locked underneath the kitchen sink. The fire extinguisher is located in the kitchen and is operable. Medication - LPA observed the resident medications, and first aid kit, are safely locked in a kitchen cabinet. The resident and staff files were also locked in the cabinet. Delayed Egress: LPA observed the delayed egress to all exits were turned off and not working. Continued on 809-C Garage//Washer & Dryer – The laundry room was locked and contained the washer/dryer. The laundry soap was stored in the room. The door leading to the garage was locked. at 11:40 am, LPA observed a section of the garage was converted into a room. LPA observed a bed, microwave, portable toilet, and a person's belongings. There is an exit out of the room to the front yard. The caregivers stated a person is renting the room. They also stated the individual uses the portable toilet at night but will go through the front door to use the restroom and shower during the day. The caregivers confirmed the resident does not receive care and supervision. Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair. Based upon the Fire Safety Inspection Request document issued by the Los Angeles Fire Department which was dated 9/2022, the facility may have five non-ambulatory residents and one bedridden resident. Bedrooms 1, 2, 3, and 4 are non-ambulatory rooms. Bedroom 5 is the designated bedridden room. LPA observed two bedridden residents living in Bedroom 1 (one) and Bedroom 3 (three). Bathrooms: The bathrooms contained hand soap, paper towels, grab bars, trash can, and slip resistant mats. When observing bathroom two, LPA observed cleaning solutions were unlocked underneath the sink. LPA observed the caregiver moved the solutions to a locked cabinet. Water Temperature: LPA tested the water temperature at 11:45 am which was 141.1 degrees F. LPA instructed the caregiver to adjust the water temperature to the hot water heat. LPA observed the caregiver did turn the temperature at 11:50 am. Contd' 809-C Surrounding Grounds : The backyard contained comfortable seating. LPA observed a spa is located in backyard. The spa cover was only cover one quarter of the spa. There was no water in the spa but a portable step was located next to the spa which allows access into the spa. Smoke/Carbon Monoxide Detectors : The smoke/carbon monoxide detectors were tested at 11:55 am. Based upon Title 22 Regulations, the following deficiency is substantiated. (See 809-D page). LPA Spaeth read the report to the Administrator, Nicole De Las Alas at 3:00 pm until 3:15 pm. The Administrator stated to LPA Spaeth that the caregiver may sign the report. LPA Spaeth also informed the Administrator that an additional unannounced visit may be warranted to address the staff living in the living room area. Exit interview was conducted, appeal rights discussed, and a copy of the report was given.