Routine inspection·June 27, 2023

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 06/27/2023 at 8:34am. LPA was met by Licensee Jung Kim and explained the purpose of the visit. Facility is licensed to serve residents over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for two (2) hospice residents. LPA OBSERVATIONS: Tour began at 9:15am and was led by licensee. The facility is a single-story building located in a residential area with four (4) client bedrooms, two (2) bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage. Staff living corridors is currently not occupied. · Front Yard: Was clean and well maintained. No hazards were observed. · Kitchen: LPA Ramirez observed kitchen cabinets near stove to contain caked-yellowish and brown splatter stain. LPA Ramirez observed the ceiling above the stove area to contain red and yellow splatter. LPA Ramirez did not observe sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in bottom kitchen cabinet, to be inaccessible to four (4) out of four (4) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in bottom kitchen cabinet to be inaccessible to four (4) out of four (4) residents in care. Kitchen sink water temperature was measured at 113.8 degrees F. · Dining Room/Living room: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed plenty of seating and lighting. LPA Ramirez observed fully charged fire extinguisher in this area. SEE 809-C for continuation. · Linen Closet: Contained plenty linens, towels, and hygiene products. · Resident Rooms 1 - 4: Bedroom 1 is currently shared and has a private bathroom. LPA Ramirez observed bedroom #1 to contain the required furnishings, linen and lighting. Resident bedroom #2 and #3 are private rooms. LPA Ramirez observed bedroom #2 and #3 to contain the required furnishings, linen, and lighting. Bedroom #4 is shared and LPA Ramirez observed the required furnishings, linen and lighting. LPA Ramirez observed a 3-inch crack inside bedroom #4 wall, near door entry. · Bathrooms: Private bathroom# 1 was observed to be clean and contained soap and paper towels. Signs promoting hand washing were observed. Water temperature in this bathroom was measured at 107.4 degrees F which is in the required 105 – 120 degrees F. Shared bathroom #2 was observed to be clean and water temperature was measured at 113.1 degrees F which is in the required 105 – 120 degrees F. LPA Ramirez observed a 3x3 inch circular hole located in shared bathroom #2, behind bathroom door and was exposing drywall. · Centrally Stored Medications: LPA observed cabinet located in dining room area to be locked and inaccessible to residents. LPA reviewed six (6) out of six (6) resident medications and Medication Administration Record (MAR). LPA Ramirez observed some irregularities on MAR for Resident #1 (R1) and Resident #2 (R2). · Backyard: LPA Ramirez observed overgrowth of weeds and grass. LPA Ramirez observed multiple beds of plants and vegetables growing throughout backyard. LPA observed plenty of seating and shade. No large bodies of water were observed. LPA observed carbon monoxide in hallways. Smoke detector was tested during visit. Administrator certificate 6029285740 was observed for Jung Kim with an expiration date of 05/15/22. Proof of fire and earthquake drill could not be provided. Staff files are maintained at facility. Thirteen (13) staff files (S1 – S13) were reviewed. Verification of staff training and orientation is missing complete date(s) of attendance. Staff have current First Aid/CPR certification. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting and Resident Rights. Staff have on-going training. LPA Ramirez reviewed and obtained a copy Infection Control Plan. Licensee provided LPA Ramirez is a copy of liability insurance, however, it does not meet the liability limits. LPA Ramirez observed posted Emergency Disaster Plan. Deficiencies are being cited during visit. Exit interview was conducted with Licensee Kim and a copy of this report, 809-D and appeals rights were provided.