Routine inspection·November 5, 2024

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual inspection using the CARE Inspection Tool. LPA was greeted and granted entry by Caregiver John Jordan after explaining the purpose of the visit. Licensee/Administrator (Admin) Grace Radford arrived shortly and was advised of the visit. The facility is a single story structure located in a residential neighborhood. Facility is licensed to operate for six (6) non-ambulatory of which one (1) may be bedridden and maintains a hospice waiver for six (6). There are five residents in care during today's visit with three caregivers on duty. LPA observed the facility to be clean, sanitary, and operational. There are six resident bedrooms and six resident bathrooms. There is one bedroom for the staff. All common areas were inspected including the attached two car garage which doubled as a laundry room. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for each residents' personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 120.0, 116.7, 118.2, 112.6, 113.0, and 117.6 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available. LPA toured the exterior portion of the facility. There is a small fenced fountain and secured sheds in the backyard. LPA observed the outdoor passageway free of obstructions. The exit gate was self-closing and self-latching. LPA observed sufficient seating and shading. Facility maintains two fire extinguishers. Both were mounted, charged, and serviced on May 22, 2024. The auditory devices and smoke/carbon monoxide detectors were tested and operational. LPA observed the emergency disaster supplies including food/water in the garage. Emergency evacuation drills are being conducted quarterly. The first aid kit contains all necessary elements. A working facility telephone number, 949-458-2510, remains available. The liability insurance is also current. LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size posted in the entry way. The Administrator's Certificate for Grace Radford expires on January 8, 2026 and on April 1, 2025 for Andy Radford. LPA conducted an audit of five residents' files and two personnel files. No discrepancies were noted. Medications were audited for five residents. No discrepancies noted. Staff and resident interviews were conducted. Based on the observations made during today's visit, no deficiency is being cited today. An exit interview was conducted with Licensee/Administrator Grace Radford, and a copy of this report was provided at the end of the visit.