Routine inspection·November 30, 2021

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced annual visit using the Infection Control Evaluation Tool. LPA met with Administrator and explained the reason for the visit. The physical plant was toured, resident files and medications records were reviewed, staff files were reviewed and food supply was inspected. Facility is licensed for a capacity of 6 in the age range of 60 and over, in which 6 can be non-ambulatory and 1 may be bedridden, and approved for 2 hospice waivers. LPA and Administrator Runette Catibog toured the facility which included the following: living room, kitchen, dining area, 2 bathrooms, 3 resident rooms, 1 staff room, backyard, and attached garage. Passageways and exits are free of obstruction. The water temperature was tested in the 2 resident bathrooms and measured between 106.5 - 118.6 degrees F which is within the required 105 - 120 degrees F. The resident bathrooms are clean and have the required grab bars in the shower and near the toilet for non-ambulatory residents. Showers also have non-skid materials. Resident bedrooms have the required furniture such as bed frames, dressers, lamps and chairs. Bedrooms also have sufficient closet space. There is a cabinet in the hallway with extra clean linen. Resident beds have the required linen and the linen is in good condition. Smoke detectors were observed throughout the facility and in each resident room. Carbon monoxide detector was observed in the dining area. Auditory devices were seen on exit doors which are required for dementia residents and were operating a the time of visit. LPA observed 1 fire extinguisher in the kitchen which was fully charged. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked under the kitchen sink and are inaccessible to residents. Cleaning supplies and toxins are locked under the kitchen sink and are inaccessible to residents. The First Aid kit located in a closet in the living room was inspected and was fully stocked with current manual. Signs are posted throughout the facility to promote hand washing, cough/sneeze etiquette, and physical distancing. Sufficient supply of 2 days perishable & 7 days non-perishable foods were observed in the kitchen and garage. (CONTINUED TO LIC809C) Medications, resident files, and staff files are kept in a locked closet in the living room. The backyard is clean and there is a shaded seating area for the residents. No bodies of water were observed in the facility. LPA reviewed 5 staff files and observed the following: 4 out of 5 staff have criminal record clearances and are associated to the facility, 5 out of 5 staff have proof of in-service training, 5 out of 5 staff files have health screenings with TB information, and 5 out of 5 staff have current first aid/CPR certificates. Staff #1 (S1) who was present at the facility does not have a criminal record clearance and facility did not have paperwork in the staff file to show that S1 has done a criminal background check. LPA reviewed 4 residents' files and medication, and observed the following: 4 out of 4 resident have admission agreements on file, 4 out of 4 have their needs and services plans up to date, and 4 out of 4 have physician's reports on file and TB information, and 4 out of 4 have their medications documented properly and given as prescribed. According to the physician's reports the facility currently has 2 bedridden residents and the facility is only licensed for 1 bedridden. Per California Code of Regulations, Title 22, and California Health and Safety Code, there was two deficiency observed during the visit (refer to LIC809-D). Exit interview held and a copy of the report and appeal rights was provided.