Routine inspection·August 11, 2022

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met with Deborah Davis, Licensee and Dan Davis, administrator, who assisted with the visit. Facility is licensed to serve six (6) non-ambulatory, of which two (2) maybe bedridden, who are age 60 and above. Six (6) hospice waivers are on file. Annual licensing fees are current. Administrator certificate is current, and the expiration date is 06/2/2023. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is single story house located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. The facility has six (6) resident bedrooms, two (2) bathrooms, one (1) staff room, living room, kitchen, dining room, and an indoor/covered outdoor activity area. All the rooms were furnished with appropriate furniture for residents’ comfort. The bathrooms were furnished with grab bars and nonskid surfaces. Common areas were observed for the ability to safely serve the needs of the residents. Hot water temperature was measured in 107.2 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies was observed. No pools and bodies of water on the premises. Facility maintained a comfortable temperature for residents. Auditory alarm devices to monitor exits were operable. Interior and exterior space available to permit residents to wander freely and safely. Sufficient supply of perishable and nonperishable foods was observed. Knives, tools, sharp items were inaccessible to residents. Smoke detectors and carbon monoxide detectors were operable. Fire extinguishers’ last service was 7/12/22 and fully charged. (-Continued LIC 809C- ) The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked cabinet in the office and inaccessible to residents. Resident records are stored in a locked cabinet and inaccessible to residents. Toxic substances are inaccessible to residents. Outdoor facility space used for residents and leisure are completely enclosed by a fence with self-closing gates. No deficiencies were observed and cited per California Code of Regulations, Title 22. An exit interview was conducted. This report was discussed with Administrator and Licensee. Signature on this form confirmed receipt of these documents. A copy of LIC 809s report was provided.