Routine inspection·July 15, 2022

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 7/15/22 at 10:15am. Administrator Certificate expires 1/30/2023. LPA met with Patricia Matias, Administrator and discussed the purpose of the visit. The facility is licensed for a capacity of 6 residents. There are 3 residents present at this time. LPA observed 2-day perishables and 7-day non-perishables. There is a hospice waiver for 2 but 0 are receiving the services at this time. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 108.3*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. 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 inquired about discoloration on refrigerator. Administrator stated that it is oxidation and the ice doesn't work for resident use. -LPA observed the LIC 500 that does not include the complete date of employment and does not indicate 24/7 coverage according to Department of labor laws. -LPA observed resident records to be incomplete either by staff and/or physician dates and signature are needed as well. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Facility Responsibility (LIC308) in accordance to Title 22 regulations Personnel Report (LIC500) with complete dates LIC308 and LIC500 to indicate 24/7 coverage following the Dept of Labor laws Administrator Certificate-Updated Per the California Code of Regulations, Title 22, Division 6, Chapter 8, in lieu of citations the facility received a Technical Violation (LIC9102) which is allowing time to correct the above mentioned items within a 30 day time span. Exit interview held, copy of report given