Routine inspection·June 21, 2024

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after explaining the purpose of the visit. Facility administrator Theresa Kholoma was notified by telephone. House manager Rudy Ignacio arrived later to assist. During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one story home with 6 private bedrooms, one of which vacant, three bathrooms including one en-suite in addition to the facility's common living areas. A detached garage is present and used for storage as well as for the live-in care staff. The access door to the detached building is confirmed to be locked. The current license and facility sketch indicate that room #6 is for use by staff only. At the time of the visit, one resident is observed to be living in that room, indicating that the facility is out of compliance with the terms of the current license. A corresponding deficiency is cited on an attached form LIC809-D. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently five residents admitted to the facility, three of which are receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Combined smoke and carbon monoxide detectors tested operational. The two fire extinguishers present are observed to be fully charged, with up-to-date maintenance. Lysol and Clorox spray bottles are observed in a bathroom cabinet under the sink. Laundry detergent is also observed to be accessible. The magnetic lock for the drawer containing all sharp instruments is also observed to be broken and non-functional during the visit. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 Corresponding citations are also issued on attached forms LIC809-D. The medication central storage was observed to be secure and reviewed for accuracy during the visit. LPA reviewed five resident files and three staff files. Background clearance are verified. One staff association for a staff member assigned to the night shift appears to be missing. Corresponding citation issued. Based on records reviewed, at least one resident death and one other resident's unscheduled hospitalization have failed to be reported to the Department, which fails to meet the Reporting Requirements present in Title 22 of the California Code of Regulations. Corresponding citation issued. Based on the observations made during today’s inspection, four type A deficiencies and three type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations along with six advisory notes provided. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.