Routine inspection·January 24, 2025

Licensing Program Analyst (LPA) Yolanda Delgado 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. Resident record review began- Five (5) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms-2 missing, identification and emergency information, appraisal needs and service plans-1 missing, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is is not meeting documentation requirements. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 117.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. Foods are dated to assure safety. Food prep areas are clean and organized. LPA began review of employee records- Five (5) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current. (Continued on next page) (Continued on from Page 1) 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 was changed in 2022 and LIC809 dated 2/15/2022 noted that facility is under renovations however no updated floor plan and no updated STD. 500 (family/living room was renovated to rooms for residents) was observed in facility's file. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 01/04/2025. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 11/20/2024. There are no firearms stored at the facility and there is a pool with a black mesh barrier fencing surrounding the exterior of the pool. LPA allocated time to prepare this report for delivery. Based on the information received during this visit today, there are two (2) deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. This report, LIC809D, Appeal Rights was reviewed with and a copy provided to the facility representative at the time of the exit interview. LPA has requested the Licensee to complete and submit LIC200 and updated floor plan to CCLD by 1/31/2025