Routine inspection·February 13, 2024

On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct an annual visit. LPA was greeted and granted entry into the facility by Caregiver Nero Kaw and explained the reason for the visit. Administrator/Licensee Angelo Buenaventura arrived at the facility at 10:30 am. The facility is licensed as a 4 bedroom 3 bathroom facility, 4 residents rooms and 1 resident bathroom and 1 staff bathroom. LPA Mendivil toured the facility with staff Nero at 9:10am. LPA Mendivil observed a fifth room, which contains a bed, dresser and personal affects of a staff member. LPA Mendivil observed all residents rooms to contain all required elements including: bed, dresser/closet space, lamp and chair. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 115.1 and 120.5 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. At 9:40am, . Smoke detectors and Carbon Monoxide detectors tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. LPA observed emergency water supply on-site. LPA reviewed the emergency disaster plan during the visit. Administrator stated the last emergency drill conducted was prior to last CCLD visit in 2021. Facility provides activities in the form of music, coloring and puzzle activities. CONT ON LIC 809C DATED 02/13/2024 At 10:00am, LPA reviewed 6 resident files and 5 staff files. Resident files contained required documents including admission agreements. LPA observed the residents files in 6 out of 6 did not contain updated physician reports and resident appraisals. Staff files reviewed contained required documentation of health screen/TB, criminal record clearance. At 11 AM, LPA reviewed medication storage and administration. LPA observed Medication Administration Records to have medication signed off until 2/18/2024, based on Administrator the facility staff pre-pours medications for the week. Facility is licensed for 6 non ambulatory residents and a hospice waiver for 2 residents. LPA observed facility to have 1 bedridden resident and 4 residents on hospice. Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.