Routine inspection·July 2, 2024

Licensing Program Analyst (LPA) Mary Flores and Michael Moriel conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Artemio de la Pena and explained the reason for the visit. The facility is licensed to serve 4 non-ambulatory residents over the age of 60, of which 2 may be bedridden in room 3 and 4. Facility has a hospice waiver for two. The facility is a single-story home in a residential neighborhood and consist of a living room, dining area, kitchen, laundry area, 4 resident bedrooms, 2 resident bathroom, 2 Staff Rooms, 1 Staff bathroom, detached garage, front yard, and back patio. LPA conducted a tour of the facility with Artemio de la Pena and observed the following: Facility is in good repair indoor and outdoor. Living room has a covered fireplace. Dining room/living room have sufficient seating area. Kitchen was observed clean, sharps and cleaning solutions were observed locked. Sufficient food was observed for at least 2 days of perishables and 7 days of non-perishables. Each client room was observed with sufficient lighting, the required furniture and bedding supplies. Room #4 was observed with a hole in the front of the door of the size of a tennis ball. Bathrooms were observed clean and in good repair. Water temperature was tested between 101.1 and 102.1 degrees F., which is not within the required 105-120 degrees F. Facility has linens and grooming supplies for residents. Smoke/Carbon monoxide detectors were tested and are in working condition. Back patio was observed and few of the floor planks are chipping down, fence is being held by a wood plank per staff the tree is pushing the fence in, exit passage way to the garage was observed with plants overgrown. No large bodies of water were observed. LPA reviewed medication and files for 4 residents and 4 staff files. Staff were missing 20 hours of training. Infection control plan was last reviewed on 6/30/22. Emergency Disaster plan was last reviewed on 7/8/22. Las fire drill was conducted on 5/28/24. Administrator certificate was observed for Anthony Shinn #6005240740 exp. date: 9/21/25. Deficiencies were noted on LIC 809D per Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.