Routine inspection·January 16, 2025

At 12:10 AM, Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with Betty Griego, the staff LPA and explained the reason for the visit. LPA was informed that the Administrator cannot come to the facility due to a full-time job. Physical tour was conducted with the staff and LPA observed the following: Upon arrival LPA was informed that the census is zero (0); however, the facility did have a resident from end of March 2024 to June 1st, 2024. LPA was informed that R1 had difficulty breathing on or before 06/01/2024, and R1 passed away. However, no death report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. Fire Extinguisher was last purchased on 09/12/23, and was full. The medication will be kept in a locked cabinet in the kitchen. BEDROOMS: There are four (4) bedrooms designated for residents use. All bedrooms have sufficient closet space and have sufficient lighting. All bedrooms were observed to be properly furnished with appropriate beddings and linens. Facility has a live-in staff at the facility. The designated bedroom for the staff is bedroom (1); however, the staff is currently using bedroom #4. Continue on LIC809-C Administrative: LPA was informed that the facility does not have a Certificate of Liability Insurance, LPA was not provided LIC 500. During today's inspection, the facility is not in compliance with Title 22 regulations. Deficiencies will be cited for today's visit. Appeal rights explained Exit interview conducted. Copy of report provided. BATHROOMS: There are total of three (3) bathrooms and LPA observed all bathrooms to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed bathroom to have appropriate grab bar and a non-skid mat . The water temperature was noted at 119°.3. The facility is using one of the bathrooms attached with bedroom #1 for staff and visitors only. COMMON AREAS: LPA observed all common areas to be clean in good repair. The facility maintains a comfortable temperature at 72°F. The living room and dinning rooms were properly furnished. No obstructions and or tripping hazards throughout the facility. LAUNDRY ROOM: The laundry room is located behind the kitchen which has an entry to garage. LPA observed a door with a lock. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision. SURROUNDING GROUNDS: The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, LPA observe a covered shaded area for residents . There is no swimming pool or bodies of water in the facility. The facility has a back-house and the owner of the house lives in it. No residents wre observed in the back house. SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. They were tested and observed to be operational. Activity Room: LPA observed an activity room for residents use with an adequate amount of activities. The activity room is located in the front of the house adjacent to living and dinning rooms. Records: Upon request of the records for staff, LPA was not provided with any records. Moreover, LPA was informed the S1 have been working at this facility since 04/20/2024. However, LPA reviewed LIS and did not observe S1 being associated with the facility. The facility had a resident from March 2024 to June 1st, 2024. LPA requested for the former resident file and LPA was not provided with one. Continue on LIC 809C