Routine inspection·March 4, 2025

On this day Licensing Program Analyst (LPA) Kimberly Lyman 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, of which three may be bedridden. Facility has an approved hospice waiver for 3 residents and the home currently has 6 residents and one tenant. Administrator Jaya Pichika has a current administrator certificate expiring on 09/13/2025. LPA Lyman along with Caregiver Berenise toured the facility at 12:41 PM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The two story home consists of 6 resident bedrooms, tenant room, owner occupied room, living room, dining room, and kitchen as well as 4 restrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident 2 (R2) has a faulty smoke detector in the resident's room. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. R1's shower handle is observed to be broken and R3's door handle is broken. Water temperature measured between 107 degrees F and 134.7 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. The downstairs common restroom has discoloration on door and a taped hole in the wall outside the restroom. 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. LPA observed rotten tomatoes, bell peppers, cauliflower and green beans as well as out of date milk in the refrigerator. Smoke detectors tested operational during today's visit. Fire extinguisher is fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. 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 and LPA observed residents participating in exercise. CONTINUED ON LIC 809C DATED 03/04/2025 LPA observed the emergency food and water supply. LPA reviewed six resident files and one staff file. All resident files contained required documentation including admission agreements, physician reports and resident appraisals. R5 does not have a physician order for bed rails. One out of two staff present do not have a staff file. Licensee to forward an updated LIC 500 to LPA by 03/18/2025. Due to time constraints, LPA to return to conduct medication audit. Based on the observations made during today’s visit, deficiencies are 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 as well as appeal rights.