Routine inspection·January 7, 2025

On January 7, 2025, at 9:10am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by House Manager (HM) Ana Santos. LPA Kim met with Assistant Administrator (AA) Gerald Dia and explained the purpose of the visit. The facility is licensed to operate for six (6) nonambulatory residents of which one may be bedridden and has a hospice waiver for six (6) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with HM Santos. There were no bodies of water or obstructions in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, and Resident Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 108.3 degrees F to 109.9 degrees F. A comfortable temperature of 69 degrees F was maintained in the facility. LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food in garage, both were available and maintained properly. Emergency food, emergency water, and emergency supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and mounted next to the dining area exit door. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (657-578-9603) remains available. The facility has an evidence of liability insurance effective March 30, 2024, and expires on March 20, 2025. Last fire drill was conducted on December 30, 2024. LPA Kim conducted an audit of resident files (R1-R5), staff files (S1-S3), and medication and medication administration record. LPA Kim conducted two (2) staff interviews and two (2) resident interviews. Deficiencies were cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. Technical violations were issued at the time of the visit. An exit interview was conducted, and a copy of this report and appeal rights were provided to Assistant Administrator Gerald Dia.