Routine inspection·January 24, 2025

Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with staff Juwita Pratiwi Elisabeth and was granted entry to the facility. Licensed capacity is (6) current census (6). LPA was accompanied by Licensee/Administrator Kristine Mangente to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to resident in care. There was a designated space for resident/staff files. LPA observed a swimming pool in backyard, gate was safely secured by locked iron a gate around the perimeter. During facility tour, LPA observed a bed mattress inside R1 closet. Licensee confirmed staff sleep inside resident closet to. LPA requested mattress to be removed. In addition, LPA Rico observed 3 out of the 6 residents had full rails and they are not in hospice. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. . Record Review: LPA reviewed (6) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed (6) resident medications. During medication audit, LPA Rico observed the facility did not have (6) resident’s PRN response documented and maintained in the resident's MAR. Licensee stated the facility does not have hospice residents. LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed the facility did not have S1 and S2 associated to the facility. Lastly, the facility did not conduct an emergency drill for over six months. Based on the observations made during today’s visit, (5) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. The facility was also issued a Civil Penalty in an amount of $1,000. An exit interview was conducted, and this report (LIC809(LIC809D)(LIC421BG) was discussed and provided to Administrator Kristine Mangente. Along with a copy of Appeal Rights