Routine inspection·November 8, 2023

Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator Lucia Totanes. The facility is licensed for a maximum capacity of 6 residents, all of which may be non-ambulatory. The facility has a waiver for 4 hospice residents. During today’s visit, the facility had a census of 4 residents, 2 of which were non-ambulatory. The facility does not have a clearance for delayed egress or secured perimeter and LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Lucia Totanes and their certificate renewal was received by the Department as of 7/3/2023. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed near or on the premises. According to the Administrator, no firearms or weapons are stored on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 115.0 degrees Fahrenheit in a private resident bathroom and 116.4 degrees Fahrenheit in a common resident bathroom. The facility’s internal temperature was measured at 75 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for resident medications and resident and staff files. 4 resident medications were observed to be stored in pillboxes with multiple days prepared. LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance and were associated to the facility. Continued on LIC809-C page... LPA reviewed multiple resident and staff records. LPA observed resident records to be incomplete and missing information. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns. Administrator will submit updated copies of LIC500, LIC610E, and Liability Insurance to the Department within 10 business days. The following deficiencies were cited per California Code of Regulations and noted on the attached LIC809-D page. LPA provided Administrator technical assistance on staff records, emergency disaster plan, and infection control plan. An exit interview was conducted with Administrator Lucia Totanes, whose signature below confirms receipt of a copy of this report, two LIC9102TA forms, one LIC9102TV forms, and the Licensee Appeal Rights (LIC9058 01/16).