Routine inspection·September 25, 2023

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Jan Sangian, who was informed of the purpose of the visit. At the time of the visit there was two (2) staff and three (3) residents present. LPA toured the exterior and interior of the facility. The facility has no bodies of water, firearms, or ammunition. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. Outdoor and indoor passageways were kept free of obstruction. The facility's backyard had shaded area for seating. LPA observed a kitchen drawer containing knives and sharp objects not locked and accessible residents during the tour. This poses a potential health & safety risk to the residents in care, a deficiency will be issued along with a plan of correction. LPA toured the kitchen. Food was stored in a safe and healthful manner. The facility had a 2 day supply of perishable food items and 7 day supply of nonperishable food items. LPA toured the resident bedrooms. LPA observed the resident's bedrooms, bathrooms, and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair and were present. The bathrooms were operating in safe and sanitary conditions and contained grab bars and nonskid mats. The hot water temperature measured 116 F. The facility had a complete first aid kit and emergency supplies. LPA reviewed staff and resident files. Staff files had the required documentation including a health screening report and current first aid/CPR certification. Resident files had the required documentation including an admission's agreement and updated physician's reports. LPA reviewed medications. Medications were dispensed appropriately according to the physician's orders. The facility was not able to provide the Infection Control Plan or Mitigation Plan to LPA during the visit. This poses a potential health & safety risk to the residents in care, a deficiency will be issued along with a plan of correction. LPA observed the exiting doors leading outside the facility had a door alarm (auditory device) attached and LPA observed the door alarm was not in operating condition for the backdoor, front door, and garage door. This poses a potential health & safety risk to the residents in care with dementia, a deficiency will be issued along with a plan of correction. LPA reviewed the facility's emergency and disaster plan. LPA inquired about the facility's last fire and earthquake drill and administrator stated they have a fire drill once a year which does not meet department requirements. Regulations for residents with dementia states a fire and earthquake drill shall be conducted every three months. This poses a potential health & safety risk to the residents in care, a deficiency will be issued along with a plan of correction. An exit interview was conducted where a copy of this report LIC809, the deficiency page LIC 809-D, and appeal rights where provided to Administrator Jan Sangian.