Routine inspection (multi-day)·January 10, 2025

Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Case Management - Annual Continuation. LPA was greeted by, identified herself to, and explained the purpose of the visit with Caregiver Victoria Dao. The facility is licensed for a maximum capacity of 6 residents, 4 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 2 non-ambulatory residents. The Administrator for the facility is Lucia Totanes and their certificate was valid and current. During visits on 12/6/2024 and 1/10/2025, LPA toured the facility and inspected each room of the facility, including resident and staff rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 115.2 and 118.2 degrees Fahrenheit in bathrooms for resident use. The facility’s internal temperature was measured at 70 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Victoria Dao, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of 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 45 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, were associated to the facility, and had a first aid certificate. Continued on LIC809-C page… LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, initial physician’s report and appraisal assessment, documents regarding safeguarding personal property, and personal rights. Review of staff files revealed that Staff 1 and Staff 2 records were not complete and were not accessible to licensing personnel during the visit. [Dao was provided with an LIC811 Confidential Names List to identify S1 and S2]. 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. Review of facility records including plan of operation revealed that the facility did not have an infection control plan or emergency disaster plan that was available for review. The following deficiencies were cited for not having an Infection Control Plan, not having an Emergency Disaster Plan, and incomplete personnel records and noted on the attached LIC809-D pages. An exit interview was conducted with Caregiver Victoria Dao, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).