Routine inspection·May 25, 2021

Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 5/25/21 at 12pm. LPA met with Designee, Staff one (S1) and stated the purpose of today’s visit. LPA contacted Administrator prior to today's visit for COVID screening. LPA was allowed entry into the facility, screened for COVID precautions, and was accompanied by Administrator throughout the inspection tour of the facility that is licensed to serve a total capacity of 6 non ambulatory residents with Hospice waiver for 2. Today's census is 5 of which 0 is on Hospice. LPA observed three of three staff associated and cleared in Licensing Information System. LPA observed Administrator Certificate expires on 9/12/2021. LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed resident rooms with required furniture and lighting, common dining and living areas, laundry room, kitchen, storage areas, and property. The temperature inside the facility was measured at 75*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 105.2*F which is within regulatory range of 105*F and 120*F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed one of two Medication Administration Records (MAR)'s to not be filled out to document of medications administered. The first aid kit was observed in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed fire extinguisher(s) last inspected on 10/6/2020, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed chemicals and knives locked and inaccessible to residents. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed emergency food supplies. The kitchen was observed clean and in good repair. LPA observed not operational vehicle parked in the driveway and Admininstrator stated it was not working and they are trying to coordinate pick up but because of COVID they have not been successful. Upon a file review the following items were discussed to be submitted with any changes annually: Administrative Organization LIC309 Designation of Administrative Responsibility LIC308 Personnel Report LIC500 Qualifications of Administrator Certificate Emergency Disaster Plan LIC610E Health Screening Report-Facility Personnel LIC503 In-service Training Program Medication Procedures Transportation Procedures Exemptions/Waivers and Exceptions First aid/CPR certificates Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.