Routine inspection·September 12, 2022

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the required 1 year inspection. LPA was greeted by caregiver Modesto Valentos and he was explained the purpose for the visit. Modesto phoned licensee Maria Tangonan and informed her of the visit. Shortly after, licensee's aunt Leonida Namuag arrived at the facility to assist with the inspection. LPA used the infection control tool to evaluate the facility. During today's visit, LPA toured the physical plant with caregiver Modesto and Leonida, food and PPE supplies were observed, and COVID-19 procedures and residents' medications were reviewed. Licensee Maria Tangonan arrived at the end of the visit to assist with the visit. The facility is a one story home in a residential area that consists of 5 bedrooms, 3 bathrooms, a living room, a kitchen, a dining room, a back patio, and attached garage. The facility is licensed to serve 6 non-ambulatory residents, of which 1 may be bedridden, all of ages 60 and over. The facility also has a hospice waiver for 6 residents. During the tour, LPA observed the living room area with sufficient seating and lighting. Social distancing signs were posted throughout the facility. All 5 bedrooms were observed to have the required bedding, furniture and storage space. The 3 bathrooms were observed to have functional showers, toilets and wash basins. All handwash stations were fully stocked with soap and paper towels for use. The hot water was tested in all bathrooms and measured within the required 105*F - 120*F. All showers were observed to have the required grab bars and non-skid mats. The food supplies was observed in the kitchen and the emergency food supplies was stored in the garage. LPA observed more than the required 2-day perishable and 7-day non-perishable food supplies. All sharps were observed to be stored and locked in a kitchen cabinet next to the sink, and cleaning supplies and toxins were stored and locked under the kitchen sink. The back patio had a shaded seating area for the residents. All walkways and entrances/exits were observed to be clear and free of debris and hazards. A fire extinguisher was observed in the hallway and in the garage- both inspected and fully charged. Sufficient PPE was observed throughout the facility and readily available for resident use. Smoke/carbon monoxide detectors were tested and observed to operate properly. (Report Continued on LIC809-C...) At 11:02AM, LPA reviewed the medication for Residents#1-#4. R1-R3 had prescribed medications that were not properly labeled, per California Code of Regulations, Title 22. At 11:30AM- LPA reviewed the facility staff roster and association list. During the review, it was discovered that (1) staff has a criminal background clearance, but is not associated to the facility. Per California Code of Regulations, Title 22, deficiencies were observed during today's visit and will be cited on the LIC809-D. Additionally, immediate civil penalties in the amount of $500 will be issued today. An exit interview was conducted with Licensee Maria Tangonan and a copy of this report and appeal rights were provided.