Routine inspection·March 15, 2024

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 3/15/24 at 1:00pm. Administrator certificate expires 8/5/24. LPA met with Victoria Kachan, Administrator and stated the purpose of todays visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 6 may receive hospice care services and 4 maybe bedridden. There is 1 residents receiving hospice care services 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 71*F which is within the required range of 68-85*F. The hot water temperature was measured at 106.8*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. The most recent disaster drill was conducted on 1/18/24. 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 2 staff and 2 resident files and conducted interviews during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Administrative Responsibility LIC308-Submit Administrative Organization LIC309-Current Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Personnel Report LIC500-Submit Health Screening Report-Facility Personnel LIC503-NA Criminal Record Clearances LIS536-Current Emergency Disaster Plan LIC610E-Submit Facility Floor Plan/Plot Plan LIC999-Current Licensing fees-Current Fire Clearance (consistent with terms and limitations of license)-NA Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-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-Current First aid/CPR certificates-Current Liability Insurance-Submit Infection Control Plan-Submit 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 todays’ report provided.