Routine inspection·April 13, 2023

Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE tool. LPA Flores met with Maria Agundez caregiver and explained the reason for the visit. Facility is licensed to serve 6 non-ambulatory residents over the age of 60, of which (6) may be bedridden, and has a hospice waiver for (6). The facility is a single home in a residential area and consist of a kitchen, a living/dining room, with 6 resident rooms, 2 bathrooms, a laundry area, a detached garage, a front yard, and a back yard. LPA Flores conducted a tour of the facility with Soila De Dios caregiver and observed the following: Facility is clean, and in good repair indoors and outdoors. Living/dining room has sufficient sitting area. Sufficient food supplies for at least 2 days of perishables and 7 days of non-perishables were observed in the kitchen. Cleaning supplies, medications, and sharps were observed locked kitchen's cabinets. A medication refrigerator was observed locked. Each bedroom has the required furniture, bedding, and sufficient lighting. Bedroom #2(BR2) was observed with half bed rails for resident #4(R4) a physician's order/request for bed rails was not on file. Bathroom #1 is used as a guest bathroom and water temperature was tested at 112.2 degrees F., bathroom #2(B2) was observed to have grab bars, and a skid mat, water temperature was tested at 110 degrees F., which is within the required 105-120 degrees F. Interlace smoke/carbon monoxide detectors were observed, tested, and in working condition throughout the facility. A fire extinguisher was observed attached to the kitchen wall and last reviewed on 1/30/23. All required postings were observed at the facility. Facility does not have large bodies of water, backyard has shaded sitting area. LPA Flores reviewed medications and files for 5 residents and 5 staff files. Medication for R4 was observed outside original box and without a prescription label and two other medications were observed, which were not recorded in R4's medication sheet. (CONTINUED ON LIC 809C) Medication for Resident #2(R2) listed in medication sheet for the month of April not tracked and staff were not if medication has been discontinued. LPA reviewed emergency disaster plan last reviewed on 12/22 and observed emergency food/water supplies stored in the garage. Last fire drill was conducted on 9/29/22. LPA Flores interviewed 3 staff and 3 residents during the visit. Administrator certificate for Nvard Gevorkian was observed #6050643740 expiration date: 12/23/22 and reviewed renewal is pending in our department. A copy of liability insurance was requested. Deficiencies will be noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Nvard Gevorkian Administrator and a copy of this report, LIC 809D, technical violaiton, and appeal rights were provided.