Routine inspection·May 30, 2023

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Caregiver Diana Castellanos. Administrator Anna Khachatryan arrived shortly after. There are currently 5 elderly residents 60 years and older and 1 resident under age 59 residing in the facility. Four (4) residents are receiving hospice care, five (5) residents have Dementia, and one (1) resident is enrolled in home health. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Records/Incident Reports, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station located in the main entrance. The Infection Control Plan and Covid-19 Mitigation Plan/MonkeyPox plans were reviewed. Operational Requirements: Facility has a current Plan of Operation at main headquarters. The facility has a Dementia Waiver in place. A Hospice Waiver for 2 is approved. A hospice waiver increase is pending approval. A fire clearance for 6 non-ambulatory adults 60 and over; of which one (1) may be bedridden in room #4. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires 5/30/2024. A surety bond is not applicable. Resident monies are not handled. Physical Plant/Environment Safety: The facility is a single-story home located in a residential area consisting of six (6) bedrooms, two (2) full bathrooms, kitchen, dining room, living room, laundry room, rear shaded patio area, and attached garage. Per Fire Marshall the facility was required to install fire doors. They were tested and observed operational. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. Fire clearance was granted on 5/4/2022 for five (5) non-ambulatory residents and one (1) bedridden resident. The facility has two (2) fully charged fire extinguishers. Smoke and carbon monoxide detectors are operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. Water temperature ranged between 101.6 - 109.9 degrees Fahrenheit. The exterior north side gate door was locked from the interior facility grounds. There is no fire clearance approved for locked perimeter fence gate. Citation was issued. Staffing: A total of four (4) caregiver staff provide care and supervision to the clients. Personnel Records/Staff Training: Administrator certificates expired 3/8/2023 . Administrator stated the renewal documents were submitted to the recertification unit but an Administrator Certificate has not been received yet. Proof of document submittal was provided. Four (4) personnel files/training were reviewed. Staff training, health clearance, criminal background clearance and 1st Aid/CPR training was verified. ***narrative continues next page*** Resident Records/Incident Reports: A total of four (4) resident files were reviewed. They included admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment/Appraisals, hospice care plans, and emergency information. RCFE complaint poster and Personal rights were observed posted in the facility entrance area. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. The facility does not have a Resident Council. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician order for modified diet is on file. Sanitation practices and kitchen cleanliness was observed. Incident Medical and Dental: Four (4) centrally stored 30-day supply of medications were reviewed. Medical and dental transportation is provided by family members. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place. The last quarterly fire/emergency drill was completed on 2/15/2023. See next page Residents with Special Health Needs: One (1) resident receives home health services. Four (4) residents receive hospice care. Postural support physician orders are on file. Half and full bed rails for mobility assistance were observed in all resident beds. Residents (R1 & R2) have full bed rails but are not enrolled in hospice. *** Only hospice residents may have full bed rails. Citation was issued. Appraisals were observed in resident files. No residents have prohibited health conditions. Per California Code of Regulations, Title 22, deficiencies were cited. Exit interview was conducted with Administrator Anna Khachatryan. A copy of the report and appeal rights were issued.