Routine inspection·July 31, 2023

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Caregivers, Jeneffer Reyes and Jesusa Sargento and explained the purpose of the visit. At 1:52pm, Administrator, Hiransha Keerthisinghe arrived and assisted LPA with the inspection. There are six (6) residents of which three (3) are in hospice care residing in the home. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and the following was inspected during the evaluation: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor screening station at the entrance of the facility. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan and was reviewed. Facility has COVID-19 signage posted in the facility. Common area surfaces are being cleaned and disinfected on a regular basis. Bathrooms have liquid soap and paper towels. Staff are adhering to infection control requirements. Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has been added to the Plan. A fire clearance is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 2/18/2024. The last fire Drill was conducted on 5/25/2023. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the persons with special needs were observed. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood that is licensed for age range 60 and over, approved for one (1) ambulatory and five (5) non ambulatory, of which 1 may be bedridden. Non ambulatory in bedrooms 2, 3 & 4, bedridden in room #4. Facility has hospice waiver for 2. In July 2022, an approved hospice waiver for four (4) residents was granted. Facilit y consists of four (4) resident bedrooms, three (3) bathrooms, living room, office area, dining room, kitchen, backyard, patio area, and an attached garage. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Smoke and carbon monoxide detectors are operational. The facility has (1) fully charged fire extinguisher located in the living room. Fire extinguisher was last inspected on 7/11/2023. Cleaning supplies and toxic substances are inaccessible to clients. Hot water temperature readings measured 109.2 deg F in bathroom #1, 109.7 in bathroom #2 and 110.8 deg F in bathroom #3 which are within the required 105-120 degrees Fahrenheit. ***CONTINUED ON LIC 809-C*** Staffing: A total of seven (7) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Administrator certificate is valid and expires on 5/12/2024. Two (2) staff f iles were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. One (1) staff has expired First Aid/CPR training. Resident Records-Incident Reports : Three (3) resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records, Restricted Health Care Plans and Hospice Records were reviewed. Resident Rights-Information: Resident personal rights are posted. Physician orders for use of full/half bed rails were reviewed in residents files. LPA conducted (3) resident interviews. Planned Activities: Information regarding Dementia is part of training for direct care staff and is included in the Plan of Operation. Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean and well maintained). Two (2) residents have a special soft diet residing at this facility. Pesticides and cleaning supplies are kept away from the food preparation areas. Plates, cups and utensils are kept cleaned and stored properly. Incident Medical and Dental: All residents have Restricted Health Care Plan and Needs and Services Plan on file. Home Health personnel services the residents in the facility. Hospice and Home Health Nurses administer suppositories to the residents. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a quarterly basis for all staff and residents. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview conducted with Administrator Hiransha Keerthisinghe. A copy of the report and appeal rights were issued.