Routine inspection·August 21, 2024

At approximately 12:30PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Licensee/Administrator, Ana De Ventura . Facility serves residents with dementia and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 6 ambulatory residents, of which 3 residents can be non-ambulatory. Facility has an approved hospice waiver for 2 individuals. Upon arrival, LPA was informed that there were 6 Residents in care and 3 staff members on-site. At approximately 1:00PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 1:10PM, LPA conducted a walk-though of the facility with Administrator. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a 1 story building with 6 Resident bedrooms, 3 bathrooms, and common spaces. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for 2 of 4 sinks in facility were found to be out of compliance with Title 22 regulations measuring at 125.0F and 125.7F (this deficiency has been cited, see LIC809D, regulation 87303(e)(2)). Facility's fire extinguishers were last inspected July 2024. Facility smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency drill was conducted July 2024. LPA reviewed staff files, resident files, and resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was centrally stored and secure. During resident file review, LPA observed that there are currently 5 non-ambulatory residents and 1 ambulatory resident residing in facility (this deficiency has been cited, see LIC809D, regulation 87202(a)). Licensee to submit new facility sketch identifying room status so a new fire clearance can be requested. Continued on LIC809C Continued from LIC809 Administrator Certificate for Ana De Ventura (6027968740) was shown to be expired with an expiration date of 09/23/2023. LPA reviewed facility documentation stating that Licensee submitted their renewal paperwork to the Administrator Certification Bureau and is pending. LPA is requesting the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 09/21/2024. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.