Routine inspection·November 30, 2023

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 11/30/2023. LPA was met by Caregiver Rodrigo Celesios and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which five (5) may be non-ambulatory. LPA OBSERVATIONS: The facility is a single-story dwelling located in a residential neighborhood and consist of five (5) resident bedrooms, one (1) staff bedroom, one (1) resident bathroom, one (1) staff bathroom, kitchen, dining room, living room, front yard, and backyard. Front Yard: Front yard is well maintained, and no hazards were observed. Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. Kitchen sink water temperature was measured at 119.3 degree F. LPA Ramirez observed chemicals and cleaning solutions, located in under kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. Kitchen appliances were observed to be clean and in working order. Dining Room/Living room/: Dining room was observed to contain one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed nearby thermostat in this area to read 79 degree F. Linen Closet: Contained plenty linens, towels, and hygiene products See 809-C Resident Rooms 1 - 5: LPA Ramirez inspected five (5) resident bedrooms and observed all bedrooms to contain required furnishings, lighting, and linens. LPA Ramirez observed proper signage indicating the use of oxygen in two (2) out of the five (5) bedrooms. LPA Ramirez medications prescribed for R2 in two different trays on top of R2’s nightstand. Per record review, R2 may not administer medication or store medication. Bathroom: Water temperature in bathroom was within 105-120 degree F. LPA observed non-slip mats in shower and grab bars near toilet. Backyard: No hazards were observed. Plenty of shade and seating was observed. Centrally Stored Medications: Medications were observed to be stored in facility hallway closet and inaccessible to five (5) out of five (5) residents in care. Emergency Drills: Staff could not provide documented proof if emergency drills conducted. Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable. Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for five (5) staff. Documented proof of required annual training was not observed. Resident Files: Five (5) resident files were reviewed. LPA did not observe required annual physician’s report for R2. Liability Insurance & Infection Control Plan: Licensee could not furnish proof of liability insurance during visit. LPA Ramirez observed updated infection control plan. Deficiencies and technical advisories are being cited. A copy of this report, 809-D, LIC 9120 and appeals rights was provided.