Routine inspection·June 1, 2023

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Licensee, who assisted with the visit. The facility is licensed to serve six (6) non-ambulatory residents who are ages 60 and above and approved for three (3) Hospice Waiver. Facility had dementia program on file. Currently, none residents on hospice. Annual licensing fees are current. LPA discussed the purpose of today's visit with staff and licensee. During the visit, LPA conducted staff/resident interviews, used inspection tool, toured the facility, reviewed food supply, reviewed medications, and reviewed staff/residents records. The facility is a single story home located in a residential neighborhood, consisted of six (6) bedrooms, three (3) bathrooms, living room, dining room, activity/sun room, laundry room, kitchen, and indoor/outdoor activity areas. Medications were centrally stored, locked and inaccessible to residents in care. All the rooms are furnished with appropriate furniture for residents’ comfort. The bathrooms are furnished with grab bars and nonskid surfaces. Common areas are observed for the ability to safely serve the needs of the residents. (-continued in LIC 809 C-) Hot water temperature is in a range of 106.5 to 108.4 degrees Fahrenheit which was within Title 22 Regulation guidelines. Sufficient of linen supplies and personal hygiene supplies were observed. All exit doors are equipped with auditory device alarms. Last fire drill was conducted on 1/2/23. Sufficient supply of perishable and non-perishable foods was observed. Refrigerators, freezers, microwaves, ovens and counter tops observed to be clean. Plates, cups, glasses and utensils are sufficient for the current census. A comfortable temperature of 73 degrees Fahrenheit maintained throughout the entire facility. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguishers were fully charged and last service was on 12/21/22. All mandated documents and signages are posted in common areas. Side and front yards are well maintained and free of debris. There is shaded outdoor area with ample seating. No bodies of water observed. No deficiency was cited per California Code of Regulations, Title 22. An exit interview was conducted. This report is discussed and provided to Licensee, whose signature on this form confirm receipt of these documents.