Routine inspection·October 24, 2024

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/24/24 at 1:00pm to conduct a Required - 1- Year Visit. LPA was met by Rosaleah Martinez Davis and stated the purpose of todays visit. LPA was allowed entry into the home that is licensed for a capacity of 4 non-ambulatory residents of which 4 maybe bedridden and 3 may receive hospice care services. LPA and Rosaleah Martinez Davis toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed there are 3 residents at this time. LPA observed the dining area, bedrooms, bathrooms, storage areas, and laundry room. LPA observed area where knives are locked. LPA observed required furniture, and lighting throughout the facility. The temperature inside the facility measured at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 117.3*F which is within the required range of 105-120*F. LPA observed kitchen area that contained equipment for cooking and storage for items such as the nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed centrally stored medications area to be locked and inaccessible to residents. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) in the home. Facility has central heating and air. Staff and resident files are made readily available for review. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Submitted prior to todays visit 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-Pending copy received 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-(if applicable)Submit Infection Control Plan-Submit if applicable 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.