Routine inspection·April 25, 2025

At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by facility Staff. Babita Dhawan, Licensee/Administrator was contacted via telephone and arrived at approximately 11:30 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with nineteen (19) residents in care. Facility has a Dementia Care Plan and is approved for 72 non-ambulatory residents, of which fifteen (15) may be Hospice and twenty (20) may be bedridden. At approximately 11:45 AM, LPA initiated a tour of the facility with Licensee/Administrator and observed the following: Facility is one story, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets/closets containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There are multiple shaded outdoor seating areas with space for activities. LPA observed residents watching TV or engaged in games and crafting activities in the common area of the facility. LPA observed books and games available to residents as well as a daily activity schedule posted. Facility has internet service but does not currently have an internet access device designated for resident use. Licensee/Administrator agrees to provide a designated internet access device for resident use to bring the facility back into compliance with regulation. The facility telephone was tested an operational during inspection. Continued on LIC809-C... Continued from LIC809... Facility's fire extinguishers were observed charged and were last serviced 03/2025. Smoke and Carbon Monoxide detectors were last inspected by the local fire department 06/2024. Facility does not currently have delayed egress doors surrounding their memory care unit but will submit for the proper permits once they decide to move ahead with installation. Facility conducts quarterly disaster drills, and the most recent drill was conducted 02/2025. LPA observed the facility's infection control plan, several first aid kit, PPE, and emergency supplies. Facility has a generator for emergency preparedness. LPA reviewed facility's emergency disaster plan last updated 04/2022. LPA reviewed five (5) resident files and five (5) staff files, and observed the following: Staff 2 (S2) and Staff 3 (S3) were missing proof of the required annual training hours, (see LIC809D). Staff 4 (S4) and Staff 5 (S5) were observed missing proof of the required first aid training. Licensee/Administrator states that both staff members are currently enrolled in first aid training and agrees to ensure that both staff members have proof of completion before their next scheduled shift. All of the remaining required documents were observed in the staff files per regulation. Five (5) of five (5) resident files were observed missing appraisal needs and services plans which comply with Title 22 regulation 87463(a), (see LIC809D). All other required documents were observed in the resident files reviewed. LPA reviewed medications and medication logs which were observed stored and maintained in compliance with regulation. Licensee/Administrator agrees to ensure that staff are aware of the required documentation standards and that all centrally stored medication and destruction records are complete. Facility assists families with coordinating medical and dental appointments as needed and uses third party transportation services for these appointments. Facility does not manage P&I. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit : LIC610D - Emergency Disaster Plan (updated) LIC500 Personnel Roster/Report (updated) continued on LIC809C... Continued from LIC809C... Deficiencies cited from the California Code of Regulations, Title 22, Division 6 and/or the Health and Safety Code. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given. Exit interview was conducted with Licensee/Administrator, whose signature on form confirms receipt of documents.