Routine inspection·September 6, 2024

On 09/07/2024 at 12:19 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with designated staff Alexandra Manwill who then called the administrator Christopher Faamausili to informed that CCLD was present. LPA Lee explained the purpose of the visit with administrator. Designated staff Alexandra assisted with today’s visit. The current census is 6 with 1 facility staff. This facility is a single story building licensed to serve six (6) non-ambulatory residents and approved for 6 hospices wavier. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room, 2 sheds, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. LPA Lee toured the kitchen and observed sufficient seven day non-perishable and two day perishable food supplies. LPA Lee observed knifes made inaccessible to residents in care. Hot water temperature was measured at 117.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in dining room and was last serviced on 03/08/2024. LPA Lee observed the facility has a has a public telephone in the dining area. Facility thermostat observed at 76 degrees Fahrenheit. LPA Lee observed toxins made inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed 4 out of 6 residents Quick MARs and it was complete. The first aid kit was checked and contained all of the required components. Continued LIC 809-C LPA Lee requested resident and staff files for review. LPA Lee reviewed 4 out of 6 resident files and 2 staff files and they were all complete. During today's visit, LPA Lee also interviewed 1 facility staff and 3 residents in care. LPA Lee reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents will be email to LPA Lee ( pang.lee@dss.ca.gov ) by 09/09/2024 by 5:00 PM by end of day: (1) LIC 610D Emergency Disaster Plan (2) Proof of Current Liability Insurance (3) LIC 308 Designation of Administrative Responsibility (4) LIC 500 Personnel Report As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted, and a copy of these LIC 809 reports were provided to the facility.