Routine inspection·October 20, 2022

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met David Yu and Vanessa who assisted with visit. The facility is licensed to serve five (5) bedridden and one (1) ambulatory residents, ages 60 and above. The facility has an approved Hospice Waiver for six (6) residents. Currently, there are four (4) residents in placement. Administrator certificate is current and the expiration date is 7/29/23 . During the visit, the infection control domain tool was used, staff and residents were interviewed, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. The facility is located in a residential neighborhood. LPA toured the facilities physical plant, indoor and outdoor. LPA observed the facility is a single-family house consisting of six (6) bedrooms, three (3) bathrooms, kitchen, dining room, and living room with a TV. Passageways, walkways, stairs and patios are free from obstructions. The entrance and side areas are free of hazards and debris. 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. 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 is observed. Knives, tools, sharp items are inaccessible to residents. Smoke and carbon monoxide detectors are dual/hardwired and operable. Fire extinguishers are fully charged. (-continued in LIC 809 C-) Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored in a locked cabinet in the hallway 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. Deficiencies were observed and cited per California Code of Regulations, Title 22 in LIC 809 D. An exit interview was conducted. This report was discussed with Administrator. Staff’s signature on this form confirmed receipt of these documents. A copy of LIC 809s report and appeal rights were provided.