Routine inspection·July 21, 2023

On 07/21/2023 at 8:05 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct caregiver, Doria Ofori, who then called administrator, Jack Ibifubara Theodore. Administrator arrived approximately an hour later. LPA Lee explained the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 6046173740 and will expire on 11/28/2023. The current census is 6 with three staff in the facility. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve six (6) non-ambulatory residents at any given time. 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. There are no bodies of water present. LPA Lee observed sufficient seven day non-perishable and two-way perishable food supplies. Hot water temperature was measured at 109.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher was last serviced on 05/17/2023. LPA Lee observed the facility has a has a public telephone in the kitchen area and the facility have the required posters posted. The facility has infection control plan and has an emergency disaster plan. Facility thermostat observed at 78 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed 3 out of 6 medication administration record (MAR) sheet and it was not complete. First aid kit was checked and is complete. LPA Lee requested client and staff files for review. LPA Lee reviewed 3 out of 5 staff files and they were complete. LPA Lee also reviewed 6 out of 6 resident files and 6 out of 6 resident 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 was given to LPA Lee during today's visit: (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610 Emergency Disaster Plan (5) Proof of Current Liability Insurance Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility. This page was created on accident. See other LIC 809-C Page The following documents will be emailed to LPA Lee by 07/28/2023 by 5:00 PM by end of day. (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.