Routine inspection·March 6, 2025

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 residents and the home currently has 3 residents. Administrator (AD) Xu Han arrived later to assist with the visit. AD Han has a valid certificate that expires on 10/15/2026. AD provided updated liability insurance that expires on 7/24/2025. LPA along with staff Marc toured the facility at 9:00 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 4 resident bedrooms, living room, dining room, staff room, and kitchen as well as 4 bathtrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 116.2 degrees F and 118 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. At 9:07am, LPA observed a bottle of laxative and medications in a plastic cup in an unlocked kitchen cabinet. At 9:10am, LPA observed 2 cameras with audio above the kitchen facing the living room. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. At 9:16AM, LPA observed a camera with audio in R2's bedroom. Smoke detectors tested operational during today's visit. Fire extinguisher was fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 11/18/2024. LPAs reviewed three resident files and two staff files. Continued on LIC809C dated 3/6/2025 Outside grounds were toured. There are no security bars or weapons on the premises. There is shaded outdoor seating for residents. Exit gate is unlocked and operational. LPA observed there is no emergency food or water supply. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of cognitive exercise, physical exercise, and walks. All resident files contained required documentation including admission agreements, physician reports, resident appraisals. Staff files reviewed contained required documentation except for the required annual training. The last annual training were conducted in 2023. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order. Based on the observations made during today’s visit, the following 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.