Routine inspection·December 27, 2021

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Administrator, Clementia Bousheri who assisted with visit. The facility has a capacity of 15 residents. The facility is licensed to serve fifteen (15) Non-Ambulatory residents, ages 60 and above. The facility has an approved Hospice Waiver for six (6) residents on file. Currently, five (5) residents on hospice . Annual licensing fees are current. LPA discussed the purpose of today's visit with administrator. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is a single story home located in a residential neighborhood, consisted of ten (10) resident bedrooms, six (6) bathrooms, reception area, Administrative office, living room, dining room, kitchen, TV room, sitting room, music/garden room, linen closet, laundry room, garage utilized as storage room and an indoor/outdoor activity area. Medications were centrally stored, locked and inaccessible to residents in care. Hallways were clean and free of obstructions. Common areas were well organized and free of hazards. Resident bedrooms had furniture, lighting fixtures and personal storage space as required. Mattress pads observed on all beds. The required amount of linen also observed. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature is in a range of 118.5 to 119.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. (-continued in LIC 809 C-) All exit doors are equipped with auditory device alarms. Last Fire Drill was conducted on 12/10/2021. Administrator certificate is current with expiration date on 4/5/2023. Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean, plates, cups, glasses and utensils for the current census. A comfortable temperature of 70 degrees Fahrenheit maintained throughout the entire facility. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged and last service was on 4/8/21. First aid kits were fully stocked. All mandated documents and signages are posted in common areas. Side and front yards are well maintained and free of debris. There is shaded outdoor area with ample seating. No bodies of water observed. No deficiency was cited per California Code of Regulations, Title 22. An exit interview was conducted. This report is discussed and provided to facility Administrator,, whose signature on this form confirm receipt of these documents.