Routine inspection·September 21, 2023

Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the annual inspection. LPA met with Irene Formentera, Area Manager and the purpose of the visit was discussed. Facility is licensed to serve six (6) non-ambulatory residents of which one (1) may be bedridden and an approved hospice waiver for three (3) residents. The facility does not handle any of the residents’ money. This home is a single-story home consisting of: (6) resident bedrooms, (3) Full bathrooms, 1 staff bedroom, living room, kitchen, dining room, laundry room (located in the attached garage), garage and an outdoor shaded patio area. At 10:20 am, kitchen 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. At 10:30 am, 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. At 10:40 am, LPA observed 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. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. At 11:00 am, LPA checked the water temperature in all three bathrooms, and each measured at 109 degrees F, 115.9 degrees F. and 116.4 degrees F. Fire drill was conducted on 8/17/2023. REPORT CONTINUED IN LIC 809C At 11:15 am, LPA observed the smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. At 11:30 am, LPA conducted records review, staff files are current however, some resident files are not current. Medication administration records (MARs) were reviewed and found to be in compliance. LPA Montoya provided a technical advice regarding this matter: Resident 1 uses oxygen in the facility. Staff 1 states the local fire department has not been informed in writing. LPA advised Staff 1 to report to the local fire jurisdiction that oxygen is in use at the facility. Deficiency cited under California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency: On 9/21/2023 at 11:30 am, based on LPA's records review, t hree residents (R1, R2 & R6) out of six residents do not have current appraisals. An exit interview was conducted and a copy of Report and Appeal Rights provided.