Routine inspection·January 31, 2025

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was granted entrance into the facility by S1 and explained the purpose of the visit. Administrator, Hiransha Keerthisnghe arrived shortly after and purpose of the visit was discussed. Administrator assisted with the tour of the facility. There are four (4) residents who currently reside within the facility. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. LPA observed that the facility has a current Infection Control Plan on file in place. Physical Plant/Environment Safety: The facility is part of a single-story home located in a residential area and contains the following: living room, dining room, office room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, (2) private resident rooms, (2) shared resident rooms, garage, (2) bathrooms for residents; bathrooms with shower, toilet, and washbasin. A back yard with shaded area and seating for resident use. There’s a laundry area; with washer and dryer in the garage. The residence is equipped with central air conditioning. There is an inaccessible fireplace. Exit doors are free of any obstruction and there are no pools or large bodies of water. All resident rooms were inspected and LPA observed resident beds and the bedding for each bed were in good condition, adequate lighting provided, storage for resident personal belongings was observed for each resident. Physical Plant/Environment Safety [Cont.]: Each resident bedrooms include all required furniture: a bed, chair, lamps, dressers, and sufficient lighting and closet space. The facility has two (2) fully charged fire extinguishers located one in the hallway and one in the dining room and inspected on 07/09/2024. Sharps were secure and locked in the kitchen drawer and inaccessible to residents. Cleaning supplies were observed in a secured area away from food in the kitchen underneath the sink. Carbon monoxide detector is tested and in working condition. Resident Bathrooms are clean and operational. Toilets and water faucets worked properly. Showers were free of mold/mildew, had adequate lighting, and there are sufficient toiletries that are accessible to residents. Grab bars observed in the bathroom. Bathrooms water temperature was tested as follow: water temperature bathroom #1 tested at 112 degrees F and bedroom #2 tested at 114.3 degrees F which is within the required 105-120 degrees F regulation. Facility temperature was comfortable and cool. LPA observed the facility to be clean and appropriately furnished with clear passageways inside and outside. Operational Requirements: The Program Design was reviewed. This home is licensed to serve age range 60 and over. (6) non-ambulatory, of which 1 may be bedridden. Bedridden in room #4. Hospice waiver for 4. Care and supervision to meet the residents’ needs was observed. Liability Insurance is confirmed and currently on file. Staffing : A total of five (5) full-time staff members provide care and supervision to the residents Personnel Records / Staff Training : Administrator certificate effective on 05/13/2026 and Training in file. Staff have the proper criminal and background clearance. Five (5) staff files for First Aid and CPR training, Personnel Record, Health Screening, TB Clearance, and Employee Rights. All other ongoing training was documented. Resident Rights/Information Physician orders were reviewed in resident files. Personal Rights is posted. Facility provides phone and internet access to residents. Resident Records/Incident Reports: Four (4) resident files were reviewed containing admission agreements, Physician's Report, physician’s orders, medical/functional assessments, TB clearance, Appraisal/Needs and Services Plan, personal rights, pre-placement appraisal, and medication records were reviewed. However, based on record review, Resident #3 (R3’s) medical assessment LIC602 Physician’s Report is signed but not dated and does not indicate the physician’s details nor length of time the resident has been under their care. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Planned Activities: LPA observed facility has sufficient activities and sufficient indoor and outdoor space for planned activities. Facility provides an activity calendar for residents with Dementia. Incident Medical and Dental: Resident medical and dental records in resident files. Facility provides transportation for residents to medical and dental appointments if needed. All medications are centrally stored in a locked closet and are properly labelled and in their original containers. LPA reviewed four (4) residents’ medications with no issues. Disaster Preparedness: Emergency and Disaster Plan was posted on the wall and reviewed. An emergency fire/disaster drill was last conducted on 12/2/2024. Residents with Special Health Needs LPA observed from record review and interview that the facility has no residents with special health needs. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit are documented on the LIC809-D. Exit Interview conducted and a copy of the report with appeal rights were provided to the Administrator, Hiransha Keerthisnghe.