Routine inspection·May 9, 2022

Licensing Program Analysts (LPAs) Celine De Perio and Albert Marin conducted an unannounced required annual inspection in this facility. Administrator Theresa Kholoma and House Manager (HM) Rudy Ignacio were informed about the presence of LPAs in the facility. HM Ignacio arrived in the facility. LPAs stated the purpose of the visit. The facility is licensed for capacity of six non-ambulatory of which 1 may be bedridden; and with hospice waiver for six. For this visit, there were three residents under hospice care. At 11:03 AM, LPAs De Perio and LPA Marin were granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure of the facility. LPAs observed five residents in care, while the sixth resident was out with a family member. LPAs observed two staff members on the floor. LPAs toured the interior and exterior portions of the facility with the House Manger, Rudy Ignacio. There were two private and two shared resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired smoke, carbon monoxide and auditory exit alarms were observed to be operational. Fire extinguisher was mounted and charged. Bathrooms were provided with grab bars, and hot water temperature was measured at 120 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. LPAs observed that knives and sharp kitchen tools were in a drawer that was not locked. LPAs observed disinfectant solutions and toxins located in a garage, however LPAs observed that garage door was unlocked and open. At about 11:15 AM, LPAs observed 33 bottles of medication in Resident #1’s (R1) bedroom in plastic boxes, opened, sealed, with some expired medication. Per file review, R1 is unable to store own medication per physician report issued on March 24, 2021. Continuation in Page 2. Continuation from Page 1 In a shared room occupied by Resident #2 and #3, LPAs noted offending odor in bedroom upon entrance at 11:25 AM. Exterior portion of the facility had patio furniture observed in to be in good repair, with a shaded area provided. At 11:28 AM, LPAs observed locked padlocks on both exit gate in the backyard. LPAs De Perio and Marin informed and reviewed the Coronavirus 2019 (COVID 19) mitigation plan of the facility with HM Ignacio. LPAs discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. For this visit, deficiencies were observed; and citations were issued per Title 22 Division 6 of the California Code of Regulations. LPAs De Perio and Marin conducted an exit interview with HM Ignacio. LPA explained the deficiencies, citations, and appeal rights to HM. Immediate civil penalty was assessed during this visit. Copies of this report, deficiency pages, civil penalty assessment, appeal rights, and cited regulations were left in the facility.