Routine inspection·January 6, 2024

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met William Carreon with and explained the reason for the visit. The facility is licensed to serve 5 non-ambulatory and 1 bedridden residents over the age of 60, with an approved hospice waiver for 6. The facility has 5 bedrooms, 3 bathrooms, a living room, a dining room, an activity room, a kitchen and an attached garage. The outdoor facility has a front yard, and back patio. LPA toured the facility with William Carreon and observed the following: Facility is in good repair inside and outside. Common areas: Living room, dining room, and TV area are clean with furniture in good repair. Fireplace is cover. Each resident rooms (5) have sufficient lighting, the required furniture and bedding supplies. Room # 2's bed was observed with full bed rails, resident is in hospice and has a request on file. Room #3's bed was observed with half bed rails, Resident #3(R3) does not have a physician's order on file. Administrator has document the request submitted to the physician. Bathrooms were observed (3) each is in working condition, showers have grab bars and skid mats. Water temperature was tested between 107.2-110.1 degrees F., which is within the required 105-120 degrees F. Kitchen was observed clean. Sharps were observed locked in a drawer. Medication cabinet was observed locked. Food supplies were observed sufficient for at least (7) days of non-perishables and (2) days of perishables and emergency food supplies are stored. Cleaning supplies were observed locked in the garage. Garage is used as storage. Backyard, passageways, and front yard are free of debris and have shaded seating area. LPA reviewed files and medication for 5 residents. Resident #1(R1) last physician's report is dated 3/3/21 and Resident #4(R4)'s last physician's report is dated 8/24/22 both residents have a dementia diagnosed, and Resident #2(R2)'s admission agreement is missing signatures. LPA reviewed 4 staff files. (CONTINUED ON LIC 809C) LPA reviewed infection control plan and disaster plan. Last fire drill was conducted on 12/1/23. Administrator's certificate was reviewed for Ralph Estanislao #6053102740 exp 3/17/25. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of report, LIC 809D, and appeal rights were provided.