Routine inspection·March 25, 2022

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Staff, Eva Nainggolan who assisted with visit and spoke with Administrator, Trupti Mody, via phone call during the visit. Facility serves. Facility is licensed to serve six (6) non-ambulatory, developmentally disabled residents who are age 60 and above. Annual licensing fees is current. Administrator certificate is current and the expiration date is 05/31/2022. All current residents were placed by San Gabriel/Pomona Regional Center (DD - Level IV (C) clients. 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 located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. The facility has five (5) resident bedrooms and one (1) staff bedroom, two (2) full bathrooms, one (1) half bathroom, living area, kitchen, dining room, and an indoor/covered outdoor activity area. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was 113.6 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers’ last service is 01/26/22 and are fully charged. ( - Continued in LIC 809 C-) The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked cabinet in the kitchen and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates. Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D. An exit interview was conducted. This report was discussed with Administrator, Trupti and Staff, Eva. Staff’s signature on this form confirm receipt of these documents. A copy of LIC 809s report and appeal rights were provided.