Routine inspection·October 11, 2023

Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 9:57 am. to conduct an unannounced annual visit. LPA met the Caregiver Ruth Aglasi at the front door and was granted entry. The Administrator Norisa Domilos arrived at 10:30am. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) non-ambulatory residents with 1 non-ambulatory resident in care. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety : The facility temperature read at 72 degrees. The facility consists of 4 resident bedrooms, and 3 bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 112 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the hallway and inaccessible to the resident. The facility and has a current fire clearance, smoke and carbon monoxide detectors and fire extinguishers and are in working order. Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings. Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, resident appraisal, client rights, and admissions agreements. (Continued on LIC809-C) Client Rights-Information: The facility has client rights information posted in the facility. Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available. Health- Related Services: The facility has a medication logbook, and the facility documents the resident’s medication and in compliance with physician’s orders and regulations. Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 10/24/19. The facility has emergency supply of food and water. Items Discussed : The last fire drill was completed on 10/24/2019. The facility has not conducted any fire drills since which is not compliant with California Code of Regulations. Summary: A deficiency is being cited per Title 22, Div. 6, Chap 8 and listed on LIC 809-D. An exit interview was conducted, Appeal Rights (LIC 9098) along with a copy of this report was provided to the Administrator Norisa Domilos and her signature on this form confirms receipt of these rights.