Routine inspection·March 25, 2024

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 3/25/24 at 8:30am to conduct a Required - 1 Year visit. LPA met with Beatrice Clark and stated the purpose of the visit. The Administrator certificate for Beatrice Clark expires 10/30/25. LPA observed the facility is licensed to serve 6 non-ambulatory residents in rooms 3-5 and the master bedroom of which 2 may receive hospice care services. There is 2 residents receiving hospice care services at this time. LPA observed fire extinguisher, smoke alarm, carbon monoxide detector in the home. LPA observed 2 day perishable and 7 days of non-perishables during this visit. During LPA visit the temperature inside the facility measured to be at 68*F which is within the required range of 68-85*F. The water temperature measured at 116.5*F which is within the required range of 105-120*F. LPA observed caregiver(s) performing other duties during this visit. 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 1 staff and 1 resident files and conducted interviews during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Criminal Record Clearances LIS536-Current Administrative Organization LIC309-Current Designation of Administrative Responsibility LIC308-Submit Personnel Report LIC500-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Facility Floor Plan/Plot Plan LIC999-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 Emergency Disaster Plan LIC610-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-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.