Routine inspection·December 2, 2024

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Adrianne Pascual and discussed the purpose of the inspection. Administrator (AD) Josephine Teehankee arrived during the inspection. LPA reviewed Infection Control requirements. At about 10:30AM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 8-bedroom, 5-bathroom, two-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA and AD observed 2 staff and 6 residents present at the facility. Resident Bedrooms: the 6 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA observed two staff bedrooms on the second floor. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested 109 degrees F and 110 degrees in the four resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 11:15AM, LPA reviewed 6 resident files and 3 staff files, interviewed 2 residents and 2 staff, and inspected medications for 6 residents. Facility does not handle resident money. CONTINUED During the inspection, LPA and AD observed the following: based on observation and admission, R1's bed contained a full bed rail but per S1 and AD, R1 is not on hospice; based on observation, the facility has two stories with staff bedrooms on the second floor but does not have an evacuation chair. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.