Routine inspection·April 17, 2024

On April 17,2024 8:30am, Licensing Program Analyst (LPA) Edward Kim and Licensing Program Manager (LPM) Lourdes Montoya conducted an unannounced required 1-year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim and LPM Montoya met with Administrative (AD) Ester De La Cruz and explained the purpose of the visit. The facility is licensed to operate for six (6) non-ambulatory residents and have a hospice waiver for 5 residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living area, dining area, kitchen, and outside covered patio area. LPA Kim and LPM Montoya toured physical plant with AD De La Cruz. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Room 1, Room 2, Room 3, Room 4, and 1 Staff Bedroom. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 134 degrees F in Resident 3 bathroom, 132 degrees F in the common bathroom, and 137.6 degrees F in Resident 2 Bathroom. A comfortable temperature of 73 degrees F was maintained in the facility. LPA Kim and LPM Montoya observed the facility to be sanitary and appropriately furnished. The Kitchen was inspected and there is sufficient supply of two (2) day perishable and seven (7) day non-perishable food available. The facility has operable smoke detectors and carbon monoxide. A working telephone (714-525-1566) remains available.. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA Kim and LPM conducted an audit of residents #1-5 (R1-R5) service files, and staff #1-#2 (S1-S2) personnel files. One out of five resident's medical assessment is not current. The following observations were made: fire extinguisher was not mounted and last serviced on 2/10/2023, facility has an outdoor make shift kitchen with refrigerator, kitchen cabinets filled with canned food and fruits and eggs on the counter, administrator's certificate expired on March 28, 2023, first aid kit was incomplete with missing tweezers, manual, gauze, medical tape, thermometer, and no activity was observed during the entire visit. Due to time constraints these deficiencies will be addressed on the continuation inspection on a later date; and staff/resident interviews and medication administration records review will be conducted on the next visit. Deficiencies were cited during this inspection visit according to the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted with AD DeLa Cruz and a copy of this report and appeal rights provided. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared.