Routine inspection·April 15, 2024

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by Administrator Teofila Mayo, Administrator. LPA discussed the purpose of the visit with Administrator Mayo. Assistant Administrator Vanessa Sanchez later arrived and joined the visit. According to the facility’s license, there may be a maximum of five (5) residents, four (4) of whom may be non-ambulatory in rooms 1, 2, and 4; and wheelchair approved in room 4 in at any given time at the facility site. The facility is approved for one (1) hospice resident. During today’s inspection, the facility’s current census is three (3) residents living at the facility. There were 3 residents present at the facility site during the inspection. LPA, accompanied by Administrator Mayo, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 74 degrees Fahrenheit (F). Hot water temperature at taps accessible to clients were also compliant: kitchen sink measured hot water temperature at 116.4 degrees F; sink in restroom #1 delivered hot water at 118.8 degrees F; and sink in restroom #2 delivered hot water at 112.6 degrees F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present, and all safely stored. There were no toxic chemicals/poisons accessible to residents. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] Medications were properly labeled, as required, and stored in locked cabinet which LPA inspected. LPA reviewed resident medications which LPA discovered that one residents medication was not provided to resident as prescribed. LPA went over Incidental Medical and Dental Care with the Administrator Mayo and Assistant Administrator Sanchez. No pools or bodies of water on the premises. Per Assistant Administrator Sanchez, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher was present (01) and serviced within the last 12 months. First aid kit(s) were complete and readily accessible. LPA interviewed staff and resident, and reviewed staff and residents’ records. During today’s visit there were 3 residents on the facility premise. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained most required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility. There were deficiencies observed and cited during today's annual inspection and may be reviewed on the LIC-809D page of this report. An exit interview was conducted and a plan of correction was jointly developed with Assistant Administrator Sanchez to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received. LPA requested Assistant Administrator Sanchez to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500, and Emergency Disaster Plan LIC 610-E to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov .