Routine inspection·September 9, 2024

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At 1:17 PM LPA Tea was greeted and granted entry into the facility by caregiver, Lesliroy Briones and explained the reason for the visit. During today’s visit, LPA met with Josefina Gutierrez the administrator of the facility. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for three. Currently there are three residents, of which one is on hospice during today's visit. Around 1:31 PM LPA reviewed one staff files and training record. LPA reviewed three of three resident records. Residents files and staff files contained all required documentation. Administrator certificate expires on November 17, 2024. At 2:14 PM LPA reviewed medication storage and administration. Medications are stored in a locked cabinet by the laundry area. Medications are being administered per physician order. LPA Tea along with the Administrator toured the facility at 2:23 PM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 6 resident bedrooms, 2 private bedrooms, 5 full bathrooms, living room, dining room, kitchen and garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms are operational except for one in the common area was not working properly but will be replaced. The nearby rooms have working fire alarms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. During the facility tour, LPA noticed a private room of a non-associated relative residing at the facility. LPA checked Guardian and the personnel roster print out on LIS and residing relative is not cleared or associated with the facility. LPA advised administrator that the relative must obtain background clearance in order to stay at the facility. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured at 116.4 F degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Annual Report continuation on LIC 809-C Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to residents in a cabinet by the laundry area. Fire extinguisher in the kitchen was fully charged. Kitchen appliances are working except for kitchen stove had one burner not working and advise administrator to repair and clean the burner. LPA toured the outside grounds and there is ample seating and the two exit gates on both sides of the facilities are self latching and operational. LPA observed emergency food and water supply in the garage. Facility provides activities based on their personal choice. Residents participate in numerous activities like walking around the facility and the neighborhood. At the time of the visit, LPA observed residents watching television. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided. The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations and civil penalties are being assessed. An exit interview was conducted with Josefina Gutierrez and a copy of these reports were given to the facility along with a copy of the LIC809C, LIC 858; 859;809-D, LIC9102TV and Appeal Rights.