Routine inspection·October 25, 2023

0900: Licensing Program Analyst (LPA) Amy Goldenberg arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. LPA spoke telephonically with the Licensee. LPA noted upon arrival one caregiver (E1), non- english speaking and five residents present. 0935: LPA Goldenberg reviewed Guardian Roster report and noted that E1 and E2 are Unknown/Volunteer status in Guardian. E1 and E2 are scheduled to work in this home today. 0955: Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 111 degrees F. Grab bars, non-slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility does not handle resident money. 1022: Personnel Records/Training/and Staffing- LPA reviewed (3) employee records. CPR requirements have been met. The facility does not employ enough staff. Upon arrival LPA observed E1 on duty alone. Review of finger print clearance revealed that E1 is cleared as a volunteer only. E2 is also only cleared as a volunteer. E1 and E2 are the scheduled staff for this facility. The facility administrator is not present a sufficient number of hours to maintain the facility as evidenced by lack of maintenance of training records, improper staffing and expired fire extinguisher dated 02/01/2019. Administrator certification is present for administrator on file, Na Zhao expired 03/26/2021. 1118: Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA reviewed five (5) resident records. 1230: Food Service- LPA was present during the lunch time meal. The meal is adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually, however the last time was on 02/01/2019. The facility is not documenting disaster drills. 1244: LPA began preparation of report for delivery. Based on the information received during this visit today, the following deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.