Routine inspection·August 11, 2023

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that three (3) clients live at this facility. There were one (1) staff member present. The Administrator, Maria Krawczyk conducted the facility tour. There is an Infection Control Plan on file. Client Records-Incident Reports/Clients Rights-Information/Dental- LPA reviewed client records. Three (3) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/and Staffing - LPA reviewed employee records. Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Maria Krawczyk’s Administrator’s license expiration date is 02/26/2023. (Continued on LIC809C) (Continuation from LIC809) Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 76 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 degrees F. Laundry is done in the hallway closet. There is a locked cabinet for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There is no fireplace at this facility. There is not a pool at the facility. There are two (2) gates that have a self-latching lock on the northwest and northeast side of the house. The facility performed their last fire and emergency drills on January 3rd, 2023. Medications - The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed if they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed six (6) fire alarms and one (1) carbon monoxide detector. The Administrator tested the smoke alarms and carbon monoxide alarms on site. There is one (1) fire extinguisher on site, last charged on 09/12/2022. (Continued on LIC809C) (Continuation from LIC809) Pursuant to the Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. LPA will be issuing a technical violation regarding, CCR 87465(h)(5)) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. The Administrator stated that she will no longer pre-fill containers and inform the family of R (2) of the regulation. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to the Administrator, Maria Krawczyk.