Routine inspection·July 23, 2021

Licensing Program Analysts (LPAs) Nune Margaryan and Tony Vasallo conducted an unannounced Required One (1) year - Inspection to this facility. Upon arrival, LPAs met with Caregivers Cordero Nelson and Tongol Alicia who assisted with the visit. The purpose of the visit was explained. Administrator Rafael Diaz also called and notified for the visit. The facility is licensed to serve 6 (six) non-ambulatory residents ages 60 and over of which 1 (one) may be bedridden and facility is approved to retain 2 residents on hospice. The facility cares for elderly residents with dementia. Currently 2 residents on hospice . LPAs Nune Margaryan and Tony Vasallo inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathrooms, laundry room, living room, and outside areas of the facility to ensure compliance with Title 22 regulations. LPAs also conducted the infection control domain tool. A physical plant tour was conducted at 9:32 am. A tour of the single-story facility includes: 2 private rooms and 2 share rooms for a total 4 bedrooms. There is 1 staff room, 2 bathrooms, a living room, kitchen, dining area, and indoor/outdoor activity area. The bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. However hot water temperature was 132.8 degree F which is beyond the required range of 105 degree F to 120 degree F not in compliance with the California Code of Regulations Title 22. The facility doesn't have a central A/C, however each bedroom is equipped with portable fans and or wall A/C units. The common areas (dining room, living room) appeared to be clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings. The kitchen was observed for the ability to prepare and serve food. LPAs observed a sufficient supply of perishables/non-perishables and emergency food supply. All mandated documents are posted in a prominent place. The facility’s smoke detectors are battery operated and were tested and observed to be operational. The fire extinguisher is fully charged and meets Title 22 Regulations. Cont. on 809C The first-aid kit was observed. There is no pool or other large bodies of water. The facility is required to have auditory devices on all exit doors due to caring for residents with dementia.. The following concerns were observed during today's visit; LPAs observed the auditory chimes on the front door and back door are missing, which is required with dementia residents. LPAs observed chemicals under the sink in the kitchen area left unlocked and accessible to the residents. LPAs observed a latch on the outside the door in bedroom #2. LPAs observed Resident #1 (R1) has prescribed daily eye drops (Brinzolamide Ophthalmic Suspension 1% and Combigan 0.2%-0.5% solution. LPAs observed bottles were sealed therefore R1 is not receiving the daily medication. LPAs observed that Residents #1; #2 ;#3 (R1; R2; R3) and Staff #1 (S1) did not have complete record at the facility. The following deficiencies were observed to be in violation of California code of Regulations, Title 22, Division 6 (refer to 809D) An exit interview was conducted, and a copy of this report was provided to the Staff along with the Appeals Rights.