Routine inspection·November 19, 2021

Licensing Program Analyst (LPA) David Sicairos conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Facility Manager Hermie Pegollo and explained the reason for the visit. Physical Plant was toured, sample record of medications were reviewed, and food supply was inspected. The following was observed/inspected: LPA and Facility Manager toured the home and inspected (3) resident bedrooms, (1) staff bedroom, (1) resident bathroom, (1) staff bathroom, kitchen, dining room, living room, and detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The water temperature was tested in bathroom #1 and measured at 66.3F which is below the required 105F - 120F degrees. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and were tested and operable during the visit. Carbon Monoxide detectors are intertwined with the smoke detectors and were operable. There are (3) fire extinguisher located throughout the facility which are fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Cleaning supplies and toxins are locked under the sink and are inaccessible to residents. First Aid kits were fully stocked with current manual. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed. (4) out of the (4) resident medications were reviewed. Medications are centrally stored in a cabinet in the kitchen. Medications are documented properly and given as prescribed. Staff and Resident files were not reviewed during today's visit. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit is documented on 809D. Exit interview held and a copy of the report along with appeal rights were provided.