Routine inspection·October 12, 2021

Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas was met by house manager/ caregiver staff, Tula Thaxter, LPA conducted a risk assessment, Based on the assessment, the facility is clear of Covid-19 infection. LPA was properly screened for Covid-19 symptoms and temperature was checked. Tula granted access and allowed LPA to enter the facility to conduct inspection. Back up Administrator, Joel Morales arrived shortly after and assisted LPA with the visit LPA verified that the facility has an approved mitigation plan report. The facility is licensed for 6 non-ambulatory residents and 6 hospice approved waivers. There are currently, 6 residents; three (3) residents are in hospice care. LPA and staff Tula both toured the inside and outside grounds of the facility. The one-story residential house consists a kitchen, dining room, living room, family room, one (1) staff bedroom, four (4) resident bedrooms, two (2) bathroom, washer/dryer room, shaded backyard patio, and two (2) storage sheds. During the tour, LPA observed the facility’s infection control practices. LPA observed a sanitizing station at the facility entrance; visitors log with Covid-19 screening and temperature log, and records of daily Covid-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional 30-day supply of PPE was observed. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the back patio. LPA observed staff and residents maintain 6 feet physical distancing, and all staff wear a face covering. All rooms were inspected. Beds in shared bedrooms are 6 feet apart. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Furniture in the living room are marked or separated, and 6 feet apart from each other. Resident bathrooms were checked, sufficient liquid soap and paper towels were observed. Toilets and water faucets worked properly, grab bars were secure, the shower was free of mold/mildew . On 10/12/21 LPA measured bathroom water temperature and observed water temperature measured at 126 degrees F. Comfortable temperature was maintained in the facility. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in a locked storage drawer. On 10/12/21 LPA observed kitchen stove burner located left back was not operable, staff turned knob and it didn’t turn on. Staff indicates burners were working earlier that morning. Centrally stored medications were observed stored in their originally received containers and kept safe and locked and inaccessible to residents in care. One (1)Carbon Monoxide and Smoke Detectors (connected) were tested and are in operable condition. On 10/12/21 LPA heard one smoke detector located in the livingroom area chirping as if battery was low charge. The facility has (2) Fire Extinguishers fully charged and accessible , extinguishers were serviced on March 23, 2021. Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions. Deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights provided via email to facility representative.