Routine inspection·June 22, 2021

Licensing Program Analyst (LPA) Shobhana Frank arrived conducted an announced annual inspection. Upon arrival LPA was greeted by facility Administrator (AD) Cotilia Dahabreh and granted entry. LPA began inspection with introduction and visit purpose. LPA toured the facility inside and outside. The facility is a single story, seven bedroom, three bathroom, kitchen, living room, family room and dining room. Staff report there are currently four residents in care of which one receiving hospice services. LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, visitors log. LPA observed COVID posters throughout the facility. LPA observe the facility to be clean and in good repair. Physical Plant and Safety of Environment/Operational Requirements. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature in resident bathroom was observed to measure 108.9 degrees F. Hallways were observed to be free of debris and clutter. The facility has a small jacuzzi located on the outdoor patio. Facility utilizes a fence around the jacuzzi. Grab bars, non-slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Reviewed Mitigation plan – LIC 808 –Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 to the California Department of Social Services (Department) all items meet the required components. Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA reviewed two resident records. The facility is meeting documentation requirements. Resident Rights are posted in the facility and a copy is signed on file. Dementia and hospice regulation requirements are being met. Personnel Records/Training/and Staffing- LPA reviewed two employee records. CPR and annual training requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the residents in care. The facility administrator is present a sufficient number of hours to maintain the facility. Administrator certification is present. Food Service- LPA observed meal being served. The meal is adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. Fire extinguishers are charged, mounted and dated 02/01/2021. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. The facility does not handle resident money. LPA spoke with residents in care who noted no concerns about care being provided. Based on the information received during this visit today, there are no deficiencies being cited in the area inspected. This report was reviewed with and a copy provided to the facility representative.