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 8:45am. 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 and upon arrival LPA screened S1. LPA was allowed entry into the facility, screened for COVID precautions, and was accompanied by S1 and Administrator upon arrival and throughout the inspection tour the facility that is licensed to serve a total capacity of 6 non ambulatory and Hospice waiver for 2. Today's census is 5 of which 1 is on Hospice. LPA observed four of four 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 76*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 118.4* and 116.4*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 clients. LPA observed two of two Medication Administration Records (MAR)'s to not be filled out to document of medications administered. S1 stated she administers medications to residents but does not sign off. The first aid kit was observed not found 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 food supplies of properly labeled and unexpired 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. LPA observed kitchen knives in a cabinet to the left of the kitchen sink with a towel blocking the lock and personal care items stating "keep out of reach of children" stored in the kitchen and restroom accessible to residents in care. The kitchen was observed clean and in good repair and refrigeration and freezer was within regulatory temperature range. LPA observed stored items not in good repair in the backyard and accessible to residents in care. Administrator stated they will contact for pick up of stored items not in use. 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 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.