Routine inspection·February 19, 2025

Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by care giving staff after explaining the purpose for the visit. Administrator (AD) Tin Le was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Tin Le's certificate expired on November 28, 2024. However, LPA verified and confirmed that Administrator Tin Le submitted an Administrator renewal application to the Administrator Certification Bureau on November 25, 2024. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents, and has a hospice waiver for four. The facility is a single story home with five resident bedrooms, one of which is shared, one staff room, three resident bathrooms, two of which are shared, a living room, a dining room, a kitchen, and an attached two car garage. LPA, accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed six residents in care and two care giving staff present. LPA observed the resident relaxing in their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected all five resident bedrooms and they were observed to be free of any hazards. LPA observed the resident bedrooms had all the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway cabinet. LPA inspected the three resident bathrooms. Resident bathrooms are clean. Resident bathrooms were equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 119.1 and 119.3 degrees Fahrenheit. LPA observed the staff room is kept locked and inaccessible to residents in care. LPA observed that the kitchen has a two day perishable and a seven day nonperishable food supply on hand. The kitchen is clean and appliances were operational. LPA observed the five burner gas stove lights unassisted. CONTINUED ON LIC809-C LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed toxins and chemicals to be stored in a locked kitchen cabinet under the sink. A fire extinguisher is located in the dining room and in the resident hallway. Fire extinguishers were observed to be charged and serviced as of May 9, 2024. LPA tested the dual smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 3, 2024. The centrally stored medication is kept in a locked closet in the living room. LPA observed a First Aid Kit to be stored in the locked closet and it was observed to have all the required components. LPA observed a fireplace in the dining room and it was observed to be adequately fenced and not in operation at time of visit. LPA observed chemicals and toxins to be stored in a locked cabinet in the resident hallway. LPA observed the door leading to the attached two car garage is kept locked and inaccessible to residents in care. LPA observed the garage to be used for storage. LPA observed the facility has a three day emergency food and water supply stored in the garage. LPA, accompanied by the AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion of the facility to be free of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the north side and south side of the facility are self-latching and can be open in an evacuation. There are no bodies of water on the premises. LPA reviewed all six resident files. LPA observed that the Reappraisals for Resident #1 (R1), Resident #3 (R3), and Resident #4 (R4) were outdated. LPA reviewed all six residents' medication and medication record. LPA reviewed two staff files. LPA observed that Staff #1 (S1) and Staff #2 (S2) did not have a Health Screening Report on file. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Tin Le. A copy of the report and Appeal Rights were provided.