Routine inspection·September 28, 2023

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 09/28/2023 at 10:27 am. LPA was met by Staff #1 (S1) and explained the purpose of the visit. Facility is licensed to serve four (4) residents ages 60 and above, of which three (3) may be non-ambulatory and one (1) bedridden. The facility provides dementia care for residents and serves developmentally disabled residents. All residents receive services from San Gabriel Valley/Pomona Regional Center. LPA OBSERVATIONS: Tour began at 10:32 am and was led by S1. The facility is a single-story building located in a residential neighborhood with three (3) resident bedrooms, four (4) staff bedrooms, three (3) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage. Front Yard: Was clean and well maintained. No hazards were observed. Front door screen is torn/ripped near the handle. Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to three (3) out of three (3) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet, to be inaccessible to three (3) out of three (3) residents in care. Kitchen sink water temperature was measured at 112.8 degrees F. Kitchen appliances were observed to be clean and in working order. Dining Room/Living room/: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed several missing curtain blinds from living room window. LPA Ramirez will issue Type B deficiency. LPA Ramirez observed fully charged fire extinguisher in this area. LPA Ramirez observed one (1) out of three (3) residents, attending day program via zoom, in living room during visit. Linen Closet: Contained plenty linens, towels, hygiene products, and extra PPE supplies. Linen closet was observed to be inaccessible to three (3) out of three (3) residents in care. SEE LIC 809-C. Resident Rooms 1 - 3: LPA Ramirez observed all three (3) resident bedrooms to contain required furnishings, lighting, and linens. Resident bedroom #1 is a shared bedroom however, only one (1) resident is currently occupying this room. LPA Ramirez observed required auditory devices to sound when resident patio door is opened. Resident bedroom #2 windows covering were observed to be dusty. LPA Ramirez with issue Type B deficiency. Bathrooms: Signs promoting hand washing were observed in all bathrooms. Water temperature in private resident bathroom#1, located in resident bedroom#1, was measured at 116.6 degrees F which is in the required 105 – 120 degrees F. Shared bathroom #2 was observed to be clean and water temperature was measured at 114.8 degrees F which is in the required 105 – 120 degrees F. Shared bathroom #3 was observed to be clean and water temperature was measured at 113.0 degrees F which is in the required 105 – 120 degrees F. Grab bars were observed near toilets and in walk-in showers, in all bathrooms. Centrally Stored Medications: LPA observed cabinet located in kitchen area to contain centrally stored medications. This cabinet was observed to be inaccessible to three (3) out of three (3) residents in care. Backyard: LPA observed a large tree branch in backyard area and was blocking a passageway to the side of the facility. According to S1, the winds knocked down the large branch on 9/28/23 during breakfast. LPA Ramirez will issue Technical Advisory. Emergency Drills: Facility could not provide emergency drills were conducted and documented since 1/12/23. LPA Ramirez will issue Type B deficiency. Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable. Staff Personnel Files: Staff files are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff. LPA Ramirez observed Administrator’s certificate for Trupti Mody with an expiration date of 05/31/2022. Per Administrator Mody, Administrator’s certificate is pending renewal. Resident Files: Three (3) resident files were reviewed. Resident#1 (R1) record did not have complete and signed medical assessment. LPA Ramirez will issue Type B deficiency. Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan. Deficiencies are being cited. Exit interview was conducted with Administrator Mody and a copy of this report, LIC 809-D, LIC 9102 and appeals rights was provided.