Routine inspection·January 9, 2025

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 1/9/25 at 1:00pm on a subsequent visit. LPA met with Lucia Boboc, Administrator and stated the purpose of the visit. Caregiver present are fingerprint cleared and associated to the facility. There are 5 bedrooms and 2 bathrooms. License fees are current. The facility is licensed for a capacity of 6 Non-ambulatory residents of which 2 may receive hospice care services. There is 1 residents receiving hospice care services at this time. Administrator Certificate expires 12/17/24. Renewal documentation has been submitted to Community Care Licensing (CCL). LPA observed an LIC308 Designation of Responsibility form. LPA observed a copy if the Infection Control Plan during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 76*F which is within the required range of 68-85*F. The hot water temperature was measured at 105*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 1 resident and 1 staff file reviewed during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Liability Insurance-Submit Designation of Administrative Responsibility LIC308-Submit Administrative Organization LIC309-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Personnel Report LIC500-Submit Emergency Disaster Plan (LIC610E)-Submit Criminal Record Clearances LIS536-Current Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-Current Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-NAt Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-NA First aid/CPR certificates-Current -Any updates to Infection Control Plan Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.