Routine inspection (multi-day)·April 11, 2025

Licensing Program Analysts (LPAs) Alberto Lopez and Sakinah Madyun conducted an unannounced annual subsequent inspection visit. LPA met with facility Administrator, Jennifer Sandoval. The purpose of today's visit was discussed. The facility has a capacity of 4 residents. It is licensed to serve elderly residents aged 60 and above, approved for 4 non-ambulatory residents of which 1 may be bedridden. The facility has two (2) Hospice Waivers on file. Annual licensing fees are current. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirement: Liability Insurance is updated and in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. 2) PHYSICAL PLANT The Passageway in the front of facility may present an obstruction, due to storage of RV camper parked in front of facility. Facility Administrator was advised to contact the fire department and get clearance to continue to have the camper parking in that space. 4. Staffing: The facility has sufficient staffing, and the night supervision staff have current CPR/first aid certification. (continue on 809C) (continued from 809) 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Some staff did not have required ongoing training. 6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, Pre-admission appraisal/Appraisal Needs & Services Plan. One resident does not have admission agreement. Resident was displaced due to fires in January 2025 and responsible party has not returned the admission agreement. 7. Resident Rights-Information: The Complaint, ombudsman and CCLD poster are not posted. entry. Visiting hours are included in admission agreement. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. Food Service: The kitchen was inspected and did not have sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be very clean and sanitary. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents. Staff purchased perishable 2-day food for facility during visit but not 7 day non-perishable 10. Incidental Medical and Dental: Some medication is centrally stored and locked in the medication cabinet in the kitchen. two (2) centrally stored resident medications were reviewed, which contained 30-day supply of medications. One resident did not have a label on PRN bottle. Some medications were accessible to residents as they were in refrigerator and in resident’s room unlocked. Disaster preparedness: The last fire drill was conducted on 03/05/25. The facility has an Emergency Disaster Plan (LIC610E) that needs to be updated. The facility has two (2) alternative temporary shelter locations. 12. Resident with Special Health Needs: 0 residents are receiving home health services. No resident is currently on postural support. Individual Service Plans and Appraisals are on file. Deficiencies observed during today’s visit. Technical Advisories provided. An exit interview was held. A copy of this report, and appeal rights were provided.