Routine inspection·December 14, 2023

Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced Required One (1) year - Inspection to this facility and met with staff Richard "Rika" Fernando, who assisted with facility tour. At approximately 11:00AM LPA met with Administrator Fernan David to assist with the visit. The facility is licensed to serve 6 (six) ambulatory residents ages 60 and over of which (4) may be non-ambulatory. Facility is approved to for (3) residents on hospice, currently the facility has (0) residents currently on Hospice Plan. LPA Calderon and "Rika" toured and inspected the facility. Facility is a single story home, physical plant includes: (3) resident bedrooms and (1) staff bedroom, and (2) bathrooms, kitchen, dining, laundry area (located in the garage), an attached garage and backyard. The bathrooms are clean and operational with grab bars and non-skid surface/mats in place. The hot water temperature was tested throughout the facility and maintained within the required range of 105-120*F. The common areas dining room and living room were clean and properly furnished, no obstructions in pathways/ hallways. Resident rooms are clean and were observed with appropriate bedding/ linen and furniture. Two (2) residents: Resident #1 and #3 were observed using a hospital bed and 1/2 rails, no physician report was provided, deficiency cited. Resident #2 sleeps in recliner due to personal choice. The kitchen was observed for the ability to prepare and serve food. Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in the kitchen and are inaccessible to residents. LPA observed a sufficient supply of perishables and non-perishables. Cleaning supplies and toxins are locked and are inaccessible to residents. Temperature maintained at the house was maintained comfortable during the visit. (Continuation LIC 809-C...) The fire extinguishers observed to be fully charged. Smoke/carbon monoxide detectors were observed to be fully operational. Administrator was unable to provide documentation on Fire Drill to LPA, deficiency noted. LPA reviewed training's, Administrator was unable to provide training in-services, deficiencies were cited. LPA reviewed resident files, Resident #1, #2 and #3 did not have Appraisal Needs and Service Plan in resident's file during review, deficiency cited. LPA was unable to review staff files, Administrator informed LPA staff files weren't present during facility visit (missing training and personnel records), deficiencies cited. LPA used staff roster LIC500 and verified staff clearance on Facility Personnel Report Summary, all staff were cleared and associated. Medication was reviewed at 2:15pm, Resident #1 , Resident #2 and Resident #3 did not have a list of centrally stored medications. LPA toured backyard and ramps, pathways and were safe and was observed clean/ no bodies of water were observed and shaded area is provided. Liability Insurance was not provided to LPA, deficiency cited. LPA conducted interview with resident #2 and did (2) attempt interviews. Administrator Certification submitted certification renewal documentation's in a timely manner, Administrator is waiting for certification with CCLD- Administrator Certification Section. Per California Code of Regulations, Title 22, deficiencies were observed during the visit and LPA issued citations. LPA Calderon provided copies of LIC809, LIC809-C, (5) 809-D pages and Appeal Rights. Exit interview conducted and a copy of the report was provided.