Routine inspection·October 11, 2022

On 10/11/22 at 9:00 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Prior to entering the facility, LPA Truong called and spoke to facility staff who confirmed no residents or staff have had any symptoms of COVID-19 in the last 10 days. LPA met with Assistant Administrator Sharon Perez and explained the purpose of the visit. Administrator holds current certification #6018430740 and expires on 7/14/2024. The facility is licensed to serve up to (6) six non-ambulatory residents. Approved hospice waiver for (4) four residents. There are currently three (3) residents who reside at this facility. LPA toured the facility with Assistant Administrator Sharon Perez on 10/11/22 at 9:20 am. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 132.2 degrees Fahrenheit, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 75 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA completed the infection control domain tool. Continued on 809-C The facility mitigation plan was submitted to CCLD, and it was approved on 4/13/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan. Administrator was informed to send updated copies of the following documents to CCL within 15 days: (1) LIC308 Designation of Administrative Responsibility (2) LIC500 Personnel Report (3) Copy of Administrator Certificate (4) LIC610 Emergency Disaster Plan (5) Proof of Current Liability Insurance Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is being cited. See 809-D for citation. Failure to correct the deficiency by the noted due date may result in a penalty being assessed. Exit interview conducted and copy of report provided. Appeal rights given.