Routine inspection·September 10, 2021

Licensing Program Analysts (LPAs) Christine Wong and Alberto Lopez conducted an annual required visit. LPA's met with caregiver Evangeline Mendoza and explained the reason for the visit. Shortly after, the administrator Alan Buan arrived and assisted with the visit. LPA's used the infection control tool to evaluate the facility. LPA's observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. Facility submitted the mitigation plan and was approved on 4/24/21 The facility is a single story house located in the neighborhood. The facility consists of 4 resident bedrooms, two bathrooms, kitchen, dining area, living room, medication/storage room and attached garage. Each bedroom has required furniture, sufficient storage space and equipment. Bedroom#1 and #2 have single bed. Bedroom#3 and #4 have two beds. Each resident bedroom has all required linen including mattress pad. All 2 bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. While touring the dining room/kitchen area, LPA observed ample food supply of two (2) days of perishables and seven (7) days of non-perishables. Storage areas for cleaning solutions, toxics, knives, and hazardous items were secured and made inaccessible to Residents. The hot water temperature measured at the two bathrooms between 115.4 degrees and 123.6 degrees F which is beyond the required 105 - 120 degrees. All the appliances are clean and working properly. The common areas such as living room and dining room are clean and have the required furniture. The back yard has a shaded area and sitting area. Carbon Monoxide and smoke alarms were tested and were operational. LPA's reviewed 4 resident files to confirm emergency contact is updated. LPA's also reviewed staff files to confirm health screenings and fingerprint clearances. LPA's reviewed 4 residents' medications. All four residents' PRN medication are missing and there's no discontinuation order. Staff reported resident does not take the PRN medication for a long time. The deficiencies cited are documented on the attached 809D. A copy of the report and appeal rights will be provided to house manager via email.