Routine inspection·March 25, 2024

On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to complete anrequired annual visit. LPA was greeted and granted entry into the facility by Caregiver Danica Mallari and explained the reason for the visit. Administrator Kevin Bim arrived shortly after. At 8:50AM LPA Mendivil toured the facility with Caregiver Danica. At 8:55am LPA Mendivil observed unsecured pre-poured medications on kitchen counter. At 8:56 am LPA Mendivil observed unsecured PRN medications on kitchen counter. At 8:57 am LPA Mendivil observed unsecured toxins underneath kitchen sink. At 9:00am LPA Mendivil observed unsecured medications in refrigerator drawer. At 9:01 am LPA Mendivil observed unsecured sharps in kitchen drawer near kitchen stove. LPA observed required department postings throughout the facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. The facility is maintained at a comfortable temperature. LPA inspected the bathroom and LPA measured the hot water temperature which measured 108 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. Bathrooms are equipped with required safety measures such as non-skid mats and grab bars. Lighting is sufficient to ensure safety and comfort. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. The facility has an available clean supply of linens. LPA inspected residents’ bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for residents in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. Facility provides activities in the form of games and exercise. LPA Mendivil reviewed 5 out of 6 residents files all except 1 contained all required documents. LPA observed 1 out of 6 residents did not have an updated LIC 602 Physician's Report. LPA Mendivil observed 4 out of 6 residents had half bed rails without physicians' order, the remaining 2 residents are on hospice. LPA Mendivil observed facility's emergency drill has not been completed since 9/12/2023. LPA Mendivil observed fireplace that was not adequately secured. LPA did not observe emergency food and water. LPA observed in 2 out of 4 residents bedrooms contained auditory monitors which provide audio from residents rooms to kitchen, without resident consent documented. 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.