Routine inspection·July 22, 2022

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Rafael Diaz, administrator who assisted with visit. The facility has a capacity of six (6) residents. It is licensed to serve elderly re sidents age 60 and above, approved for six (6) non-ambulatory, of which one (1) may be bedridden. Facility approved for two (2) hospice waivers. The facility cares for elderly residents with dementia. Currently, three (3) dementia residents are residing at the facility. Annual fees are current. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is located in a residential neighborhood, a single-story home and consisted of one (1) staff room, two (2) bathrooms, living room, kitchen, dining area, and indoor/outdoor activity area. Administrator certificate is current and the expiration date is 10/17/2023. A physical tour was conducted. Residents’ rooms were well furnished and in compliance. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. No firearms on the premises. Facility maintained a comfortable temperature for residents. Interior and exterior space available to permit residents to wander freely and safely. (-continued in LIC 809 C-) Sufficient supply of perishable and nonperishable foods is observed. Knives, tools, sharp items are inaccessible to residents. Smoke detectors and carbon monoxide detectors are operable. Fire extinguishers are fully charged. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked cabinet in the kitchen and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates. Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D. An exit interview was conducted. This report is discussed and provided to facility Licensee /Administrator, whose signature on this form confirm receipt of these documents. A copy of appeal rights was provided.