Routine inspection·April 22, 2024

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual required inspection. LPA met with facility staff Eliki Seruvatu, and explained the purpose of the visit. Administrator Unaisi Waqalala was contacted via cell phone by the facility staff. LPA observed one (1) staff and six (6) residents in care. Staff was observed preparing lunch for the residents in care. Today, lunch was pepperoni pizza and salad along with a choice of beverage. Three residents were observed watching television while eating lunch, one in their room watching television, another resident having a family and Chaplin visit, and another resident eating lunch with their family. LPA Valerio and staff E. Seruvatu toured the facility to ensure compliance with Title 22 regulations. LPA observed the front living room space to be clean, furnished, and free from debris. LPA observed five (5) resident bedrooms. Resident bedrooms were clean, furnished, and free from debris or odors. LPA observed one (1) staff bedroom, which was located inside the house. Resident bathrooms were observed to be stocked with paper towels, toilet paper, skid mats, hand rails, soap, hand sanitizer, and a trash can. Hot water was measured at 105.0*F degrees. Technical assistance (TA) was provided for the sink located in the "staff" bathroom. The sink faucet handle was observed to be loose and will need to be repaired. According to staff, residents have access to use the bathroom. The common area and kitchen area was observed to be clean and free from debris. The facility had a food supply to meet the minimum requirements of two (2) days of perishable food items and seven (7) days of non-perishable food items. The kitchen stove was observed to have a missing door handle with a screw sticking out of the door. A picture was obtained for reference. According to staff, staff utilize the smaller conventional oven for every items and only use the large oven as needed. LPA observed sharps, chemicals, and medications to be locked and inaccessible to residents in care. Continues on LIC 809 - C... Continued from LIC 809 LPA observed the garage area. LPA observed the garage to have furniture, a bed with a pillow, a couch, and other storage items. According to staff, the bed is not used for sleeping and utilized as a break area. LPA reviewed the facility sketch submitted during the pre-licensing inspection. The facility sketch submitted along withe the facility sketch posted at the facility does not indicate the garage to be a staff area. A picture was obtained for reference. The facility's last fire drill was conducted November of 2023. LPA observed the fire detector and carbon monoxide detector to be in working condition. The facility fire extinguisher located in the kitchen was observed to be expired as evidenced by the arrow pointing in the red area and a previous annual maintenance of April 04, 2023. Due to this violation, facility staff was informed that the licensee will be cited and an immediate civil penalty will be assessed today in the amount of $500.00. A signature was obtained on the LIC 421IM. LPA reviewed four (4) staff files. 2 out of 4 staff files reviewed were observed to be missing annual training documentation. 4 out of 4 staff files were observed to have a current first aid certificate. LPA reviewed three (3) resident files. 1 out of the 3 resident files reviewed were observed to be incomplete. One resident file was missing their annual Appraisal & Needs and Service Plan. LPA requested the following annual documentation be sent to the Regional Office by 04/29/2024: An updated LIC 500, updated LIC 308, updated LIC 309, updated LIC 610, and a copy of current liability insurance. Per California Code of Regulations (CCR) - Title 22, deficiencies are being cited on the attached LIC 809 - D page. Appeal rights were provided. An exit interview was held, and a copy of the report was provided.