Routine inspection·July 21, 2025

At approximately 10:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Minerva Villegas, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with 27 residents in care. Facility is approved for 46 non-ambulatory residents, 10 of whom may be bedridden, and has a Hospice waiver for 12. At approximately 11:15 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story building, was a comfortable temperature, and passageways were free from obstructions. Facility has agreed to post warning signs at al faucets and showers that test above the allowable water temperature range of 105 to 120 degrees F per Title 22 regulations in order to bring the facility into compliance. LPA observed a supply of hygiene products, clean linens, paper products, and incontinent care briefs available for residents. Residents' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were 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 is a covered seating area in the two courtyards with outdoor space for activities. Facility has internet available to residents in care and the phone was tested an operational. Facility agrees to purchase an internet access device and have it available to residents in care. Facility's fire extinguishers were observed charged and were last serviced 07/2025. Facility Smoke and Carbon Monoxide detectors were tested during facility's annual fire inspection 05/2025. Continued on LIC809-C... Continued from LIC809... Facility conducts quarterly disaster drills with the most recent drill conducted 04/2025. LPA observed facility's infection control plan and emergency disaster plan which was last updated 05/08/2025. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights for emergency preparedness. Facility has a generator. Administrator provided LPA with a copy of the facility's current liability insurance. At approximately 1:30 PM, LPA reviewed six (6) staff files and five (5) resident files. Six (6) of six (6) staff files reviewed have all of the required paperwork and proof of current CPR training. Staff 1 (S1) was missing proof of current first aid training. Administrator registered S1 for the training during today's inspection to ensure the facility is operating in compliance moving forward. Additionally, six (6) of six (6) staff files reviewed were missing proof of the required annual training and annual medication training hours per regulation, (see LIC809Ds). Five (5) of five (5) resident files reviewed have all the required paperwork. Administrator and residents' families coordinates medical and dental visits for the residents and transportation to and from their appointments. Facility contracts with a third party vendor to provide transportation services as needed.. At approximately 4:00 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. Facility does not manage P&I for residents. 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, or repeat violations within a 12 month period, may result in a civil penalty assessment. Exit interview conducted with Administrator whose signature on form confirms receipt of documents. Appeal rights provided.