Pre-licensing visit·March 20, 2023

On 3/20/2023, Licensing Program Analysts (LPA) Melissa Ruiz conducted an unannounced Pre-License visit to this facility and met with Administrator Slava Shcherba. This is a Change of Ownership Application from facility license number # 197609485 to # 197610363 . A fire Clearance dated 11/15/2022 was received for six (6) residents, of which five (5) could be non-ambulatory residents, and one (1) bedridden in room #3. Facility has a hospice waiver for four (4) residents. The purpose of today’s visit is to inspect the facility to ensure compliance, under California Code of Regulations, Title 22, Division 6. At 11:15 a.m., LPA conducted a physical plant tour inside and outside and observed the following: The facility has separate carbon monoxide and smoke alarm system. At 11:00 a.m., fire extinguisher was observed to be expired. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are (4) resident bedrooms, two of which are (2) private and two (2) are shared. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen, and dining areas) were appropriately furnished, and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records are stored in a locked cabinet in the designated office area. Medications are centrally stored and locked. The first aid kit is readily available. There are two (2) bathrooms and at 11:20 a.m., chemicals and cleaning supplies were observed to be accessible to residents in care. Trash cans were not observed to have closed tight fitting lids. (cont, LIC809-C) The kitchen knives are stored in a locked cabinet. The kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. The laundry area is outside. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional. There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. The garage is attached to the house and is kept locked and inaccessible to residents. The garage is currently being used as a laundry area, emergency and perishable food and other supplies storage such as PPE. There is no body of water in the facility. Deficiencies issued under facility # 197609485. This report will be forwarded to the Centralized Application Bureau (CAB). Contingent upon completion of the following, you will be notified by the CAB Analyst when your license has been approved. The licensee shall provide the following no later than 3/31/2023: · New fire extinguisher that is fully charged · Photos showing new locks have been placed in the kitchen and bathroom cabinets · Trash cans with lids for all trash cans · Receipt and pictures of emergency food supply Exit interview was conducted with Administrator Slava Shcherba. A copy of this report was signed and delivered.