Routine inspection·May 5, 2023

Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection on 05/05/2023 at 8:35 AM. LPA Lee met with care staff Cleopatra Gardiner and explained the purpose of the visit. Care staff assisted with today’s visit. The census today is three (3). LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility has one public telephone one in the common area. The facility has the required posters posted in the facility. This facility is a single story building licensed to serve six (6) non-ambulatory residents with one (1) hospice waiver. LPA observed the facility to be free of odor and clean. LPA observed three (3) resident's bedroom missing window screens. LPA also observed two (2) windows in the kitchen missing window screens. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. The resident bathroom water temperature measured at 114.6 degrees Fahrenheit which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in good repair. Fire extinguisher was last serviced on 05/01/2023. Facility thermostat observed at 70 degrees Fahrenheit. LPA checked medication storage and found medication to be locked away and inaccessible to clients. LPA reviewed 4 out of 4 resident medication administration record (MAR) and it was complete. First aid kit was checked and is complete. LPA requested resident and staff files for review. LPA reviewed 4 out of 4 resident files and 2 out of 4 resident files were not complete. LPA reviewed 2 out of 2 staff files and 2 out of 2 staff files were not complete. 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. Continued LIC 809-C The following documents will be email to LPA Lee during by 05/12/2023 by 5:00 PM business hour: (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Proof of Current Liability Insurance (4) LIC 610 Emergency Disaster Plan As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.