Routine inspection·May 4, 2023

Licensing Program Analysts (LPAs) Avelina Martinez and Pang Lee made an unannounced visit to this facility to conduct an annual required inspection on 05/04/2023 at 2:00 PM. LPAs met with Wane Tambunan and Juli Susanti Gultom and explained the purpose of today's visit. LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room of the facility to ensure compliance with Title 22 regulations. Administrator holds current certificate. The facility is licensed for five non-ambulatory residents. There are currently five residents who reside at this facility. The facility is approved for a hospice waiver for one resident. The LPAs toured the facility with Juli Susanti Gultom on 05/04/2023 at 2:45 PM. The facility has and adequate food supply, and the kitchen was sanitary. The facility water temperature measured at 110 degrees. In addition, all toxins were made inaccessible to clients in care. The resident bed rooms and bathrooms were furnished, and the facility has a public telephone. The facility has an area for visitors and has covid-19 postings throughout the facility. The facility has the required posting throughout the facility. The facility hall light was not in good repair. LPAs inspected smoke detectors, carbon detectors, and fire extinguisher, which they were all in good repair. the facility has a first aid kit. The facility resident and staff files were current. LPAs conducted a medication file review. LPAs reviewed two medication files. The two medication files did not have a current Centrally Stored Medication and Destruction Records. As a result of this visit, the following deficiencies were cited, per California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of the 809 report, 809-D page, and appeals right given were given to the facility at the end of visit.