Routine inspection·February 15, 2024

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:15AM to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit. Administrator, Christine Arnke arrived shortly after. LPA and Administrator initiated a walk through of facility at approximately 9:30AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 115 and 116 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is rotated and stored in the hallway closet. LPA observed an ADU in the backyard. Per conversation with Administrator, only the Owner/Administrator stays in the house when they are in town. LPA and Administrator discussed that only people who have been background cleared and are associated to this facility are able to stay in the ADU. In addition, LPA and Administrator discussed that Community Care Licensing (CCL) must be notified prior to any construction on facility grounds. Fire extinguishers were last serviced 10/06/2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 01/19/2024. Continued on LIC 809-C Continued from LIC809 Five staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Administrator certificate for Administrator, Christine Arnke (6058377740) expired on 08/08/2023 and is on the pending list for renewal. Medications and medication records were reviewed. During medication review, LPA observed that (Resident 1's) R1's Centrally Stored Medication Log reflected a start date of a new bubble pack with the date 02/07/2024. However, Resident 1 moved into facility on 02/10/2024. Should the medications have begun on 02/07/2024, there would be a total of 7 medications administered from the bubble pack. In addition, facility keeps a Medication Administration Record that indicated that medications were successfully administered to R1, however the medication bubble pack reflected that less than 7 days of medications were successfully administered. Centrally Stored Medication Log was not accurate. LPA is requesting the following to be submitted to CCL by 03/15/2024: Permits for ADU Updated facility sketch reflecting ADU on property Proof that ADU was cleared by Fire Department LIC308 Designation of Facility Responsibility LIC 500 Personnel Report Liability Insurance LIC 9020 Resident Roster 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, and appeal rights discussed and provided to Administrator. Signature on form confirms receipt of documents.