Routine inspection·March 12, 2025

On 03/12/2025 at 8:28am Licensing Program Analyst (LPA) Zina Brown arrived at the facility. At 8:45 am LPA entered the facility to conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection. At 9:35 am, the administrator Antonia Dionisio arrived to the facility and met with LPA who discussed the purpose of the visit. Facility is licensed to serve six (6) non-ambulatory residents and an approved hospice waiver for 1 resident (in bedroom #3 only) with garage only for storage use. One (1) resident is diagnosed with (1) dementia, (1) resident is receiving hospice care services and (2) receiving home health. The facility does not handle any of the residents’ money. The facility fees are current. The facility has liability insurance with Kinsale Insurance Company (Policy # 0100278106-1) effective 01/12/2025 - 01/12/2026 with each occurrence is $1,000,000 and general aggregate is $3,000,000. The home is a single story which consist of: (4) resident bedrooms, (2) bathroom, a living room, a family room/activity area, a kitchen with dining area, a laundry room, a garage for storage and a backyard with an outdoor shaded patio area. Between the hours of 9:10am - 9:25 am, LPA conducted a records review of the Medication Administrator Records for (6) residents. Between hours of 9:55 am - 11:13 am, LPA conducted a records review for (6) resident records, (3) staff records and reviewed the facility disaster plan. All client & staff records were complete. The facility disaster plan was current and in compliance with Title 22 at the time of visit. Between the hours of 12:15pm - 12:28pm, LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured at 111.0F, 114.6F, and 115.9 F. The resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Report continues on LIC 809-C. K itchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8); LPA observed the following deficiencies: Between the hours of 9:55am - 11:13am, LPA conducted a record review and observed following: NO LIC 625: Appraisal and Needs/Service Plan for Resident #1 who is diagnosed with dementia. NO TB Test results on file for Administrator (A1). An exit interview was conducted, and a copy of Report and Appeal Rights were provided.