Routine inspection·May 14, 2021

Prior to today’s visit Licensing Program Analyst (LPA) Victoria Brown contacted the Licensee with the following questions: In the last 10 days has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms: not associated with a pre-existing condition? ​ · Fever or chills ​ · Cough ​ · Shortness of breath/difficulty breathing · Fatigue ​ · Muscle or body aches ​ · Headaches ​ · New loss of taste or smell ​ · Sore throat ​ · Congestion or runny nose ​ · Nausea or vomiting ​ · Diarrhea​ Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? ​No Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE?​ No Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? ​No Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? No Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? No Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? No Licensing Program Analyst(s) (LPA) Victoria Brown and Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 5/14/21 at 2:45pm. LPAs met with Reyna Ly Romero, Caregiver who contacted the Administrator regarding todays visit. LPA's was allowed entry into the facility that is licensed to serve a total capacity of 6 residents of which 5 maybe Non-ambulatory and 1 bedridden. Administrator arrived within 15 minutes to assist with todays visit. Administrator Certificate expired 10/23/2020, the classes and fees were completed. The Administrator is waiting to receive the updated certificate. LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents. The temperature inside the facility was measured at 78*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 106.6*F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. There is 1 resident receiving hospice services at this time. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed expired foods that will be cited during this visit. LPA's observation consisted of expired food in the refrigerator such as cheese, milk, cream, mustard, pesto, ketchup and there were other items with no expiration dates such as fish in the freezer. Facility shall at all times maintain food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Administrative Responsibility LIC308 Liability Insurance Personnel Report LIC500 Qualifications of Administrator/Facility Manager- Once received from the Department Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.