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 the visit. The facility has a capacity of six (6) residents. It is licensed to serve elderly residents 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, facility has three residents with dement ia . 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 three (3) resident’s bedrooms, three (3) bathrooms, living room, kitchen, and dining room. Administrator certificate is current and the expiration date is 10/17/2023. Last fire drill was conducted on 04/19/22. 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. Hot water temperature was measured at 117.5 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies were observed. No pools and bodies of water on the premises. No firearms on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. (- continued in LIC 809C-) 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. Mandated documents and signages are posted in common areas. 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.