Routine inspection·January 16, 2025

On this day Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents, with 3 residents on hospice. Administrator (AD) Mercy Ang arrived shortly to conduct facility tour. AD Ang has a certificate renewal in process which was received on 10/10/2024 . AD provided updated liability insurance that expires on 7/1/2025. LPAs along with Administrator Ang toured the facility at 8:15 AM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 5 resident bedrooms, living room, dining room, and kitchen as well as 4 restrooms and 1 staff bedroom. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 107 degrees F and 117.8 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory alarms were operational during today's visit. LPAs toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 11/10/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise, music, and pet therapy. CONTINUED ON LIC 809C DATED 1/16/2025 There is shaded outdoor seating for residents. At 8:40 AM, LPAs observed the exit gate is unable to close due to structural issues. LPAs observed the emergency food and water supply. LPAs reviewed five resident files and two staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medication Administration Record (MAR) is not updated daily. Based on the observations made during today’s visit, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.