Routine inspection·February 6, 2025

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 2/6/2025 and was greeted by Caregiver Lorraine Yee. Administrator Deborah Davis arrived shortly after. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling.LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Resident bedroom#4 is currently unoccupied, and shared resident bedroom#2 currently only has one (1) resident. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed non-slip mat in showers. Shower was observed to be wheelchair accessible. LPA Ramirez observed the facility den was converted into a resident room. The licensee must obtain prior approval from this licensing agency to change plan of operation, including facility sketch. LPA Ramirez will issue type B violation based on observation. Food Service: LPA Ramirez observed sufficient supply of nonperishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 1/3/2025 and 11/3/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry. See 809-C Residents with Special Needs : LPA Ramirez observed a pool with a locked gate around it. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication closet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for Deborah Davis was received by Administrator Certification Bureau and is pending. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for five (5) non-ambulatory and one (1) bedridden. During resident record review, LPA Ramirez observed Resident#1’s (R1), Resident#2’s (R2), Resident#4’s (R4), physician report indicated they are bedridden. The facility fire clearance is approved for one (1) bedridden only. LPA Ramirez will issue a type A violation and assess a $500 civil penalty. This facility may retain no more than six (6) hospice residents. There were three (3) residents under hospice care during inspection. Resident Records/Incident Reports: LPA reviewed resident records for four (4) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. Two (2) violations were observed and cited during this annual inspection. One (1) civil penalty was assessed during this annual inspection. Exit interview was conducted. A copy of this report, 809-D, LIC 421IM, and appeals rights was provided via email.