Routine inspection·May 24, 2023

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection on May 23, 2023 2:15 PM-3:45 PM. 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. Two (2) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. LPA began review of employee records. Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results; missing TB date for S1, 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. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. The following Care domains were completed during the inspection: Personnel Records-training, Staffing, Resident Rec-Incident Reports, Infection Control and Food Service. (Continued on next page) (CONTINUED FROM LIC809) based on the information received during this visit today, one (1) deficiency is being cited per Title 22, Division 6 of The California Code of Regulations. Due to time constraints, Inspection will need to be completed on another day. This report was reviewed with facility representative and a copy will be emailed and confirmation of receipt will be requested. Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to complete the annual inspection on May 24, 2023. Upon arrival LPA was greeted by facility staff and granted entry. LPA began conclusion of the inspection. 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 105.0 degrees F. 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. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. 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 and were last done so on 01/23/2023. The facility is not documenting emergency disaster drills. Unknown the last disaster drill was conducted. (Continued on next page) (CONTINUED FROM LIC809C) Based on the information received during this visit today, two (2) deficiency is being cited per Title 22, Division 6 of The California Code of Regulations. This report, LIC809-D and Appeal rights was reviewed with facility representative and a copy will be emailed and confirmation of receipt will be requested.