Routine inspection·October 20, 2022

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 4 staff were on duty, including facility administrator (AD) Alan Shelley and house manager (HM) Madison Shelley. As of 10/20/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance of the facility. The PUB475 "See Something, Say Something" poster was also observed in the facility hallway. LPA observed the Administrator's Certificate for Alan Shelley, which expires on 3/24/23. LPA De Perio toured the interior and exterior portions of the facility with HM Shelley. The facility is a single level structure and is licensed for 6 non-ambulatory residents of which 0 may be bedridden and there is a hospice waiver for 4. For this visit, there are a total of 5 residents in care, of which 4 are on hospice. There are a total of 6 bedrooms, of which all are private rooms for residents. There is a pull-out bed located in the hallway and is for staff use. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms, of which were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 113.2 degrees Fahrenheit and hand washing signs were also posted in each restroom. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located under the medication cabinet. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the facility hallway. Facility had back-up emergency food and water supply, located in the kitchen pantry and in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the backyard shed. Medications were locked in the kitchen and inaccessible to residents in care. Toxins were also observed to be locked and inaccessible to residents. For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which both were self-closing and self-latching. No bodies of water were observed. LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Shelley and HM Shelley. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPA De Perio discussed with AD Shelley and HM Shelley to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov . LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Shelley and HM Shelley. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. LPA De Perio advised AD and HM to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. LPA De Perio conducted an exit interview with AD and HM and a copy of this report and copies of the regulations discussed were provided to the facility.