Routine inspection·March 3, 2025

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents which one may be bedridden. Facility has an approved hospice waiver for 4 residents and the home currently has 4 residents, with 4 residents on hospice. Administrator (AD) Josephine Teehankee arrived shortly to conduct facility tour. AD Teehankee has a valid certificate that expires on 11/19/2026. LPA along with AD toured the facility at 9:40 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 6 resident bedrooms, staff room, living room, dining room, and kitchen as well as 5 bathrooms. 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 114.6 degrees F and 116.4 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 exit alarms were operational during today's visit. LPA 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. At 10:00am, LPA observed locks under the kitchen sink non-operational housing cleaning supplies. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA 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 3/1/2025. 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. There is shaded outdoor seating for residents. Continued on LIC809-C dated 3/3/2025 Exit gates are unlocked and operational. LPA observed the emergency food and water supply. LPA reviewed four 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. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Based on the observations made during today’s visit, the following 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 along with appeal rights.