Routine inspection·March 5, 2024

Licensing Program Analysts (LPA’s) Shannan Hansen & Julie Florio conducted an unannounced required annual inspection of this facility and met with Licensee/Administrator Elvira Gazal. Facility has 6 residents in care, 1 receiving hospice care and 4 residents with dementia diagnosis. At approximately 9:00 AM LPA’s toured the building and grounds with Licensee, which was found to be clean and in good repair. LPA's observed all walkways and exits to be unobstructed. Some residents have call buttons which sound in kitchen area. All notices that are required to be posted have been posted and are in a highly visible area. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in locked garage and locked hallway closet. Water temperature measured between 116.4 and 118.7 degrees F which is within regulation between 105 and 120 degrees F in 2 out of 2 faucets accessible to residents. There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. Fire extinguisher inspected was last charged on 1/2/2024. Smoke detectors and Carbon Monoxide detector was tested and found to be in working order. Facility has fire pull station located by front door. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in kitchen along with small refrigerator with lock for medication. Facility to ensure that approved Admissions Agreements are always posted and/or accessible to public view in the facility as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement , modifications and attachments, or notice of their availability from the facility.” Continue on LIC809-C Continued from LIC809 At approximately 10:00 AM, LPA’s reviewed 6 of 6 resident records and found 6 of 6 residents have current physician’s reports or care plans. 6 of 6 resident records contained current and signed admission agreements and physician’s orders on file. At approximately 11:20 AM, LPA’s reviewed 4 of 4 staff records. 4 of 4 records contain documentation of completed training records as required. Evidence of current first aid and CPR training were observed. Medications were centrally stored in locked cabinet in the facility kitchen. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 3/5/2024 at approximately 1:00 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate. At approximately 12:30 PM, LPA’s reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts quarterly disaster drills with the last disaster drill conducted on 2/1/2024. Elvira Gazel Administrator Certificate 6008643740 expired 1/12/2024 LPA observed pending certification received 10/23/2023. LPA reviewed Licensing Information System (LIS) with Licensee who stated that is correct and updated at this time; no need to change any of the information. No deficiencies cited during today’s inspection LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 3/25/2024: LIC 308 Designation of Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (if changed) LIC 9020 Register of Facility /Resident’s Control of Property – Lease or Deed Copy of Administrator’s Certificate Proof of Liability Insurance