Routine inspection·January 26, 2024

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 Licensee Rigoberto Garcia. The facility is licensed for a maximum capacity of 6 residents, 5 of which may be non-ambulatory. The facility has a waiver for 2 hospice residents. During today’s visit, the facility had a census of 4 residents, 1 of which was non-ambulatory. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Rigoberto Garcia and their certificate expired on 6/21/2023. Review of the Department's Pending Administrator list revealed Garcia's renewal application was received on 5/9/2023 and was determined to be incomplete. 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 Rigoberto Garcia, 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 115.2 degrees Fahrenheit and 118.6 degrees Fahrenheit in two common resident bathrooms. The facility’s internal temperature was measured at 71 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. Resident medications are stored in their original container and label. 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. Continued on LIC809-C page... LPA observed linens and hygiene products provided to the clients 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. LPA reviewed multiple resident and staff records. Review of resident records revealed that 1 of 4 resident records did not have an updated physician's report as required for a diagnosis of dementia. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. 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. The Licensee will submit copies of the LIC500 Personnel Report, LIC610E Disaster Plan, and current liability insurance to the Department within 15 business days. The following deficiencies for updated physician's report, Department review of records, and Certified Administrator are cited per California Code of Regulation, Title 22 and noted on the attached LIC809-D pages. An exit interview was conducted with Licensee Rigoberto Garcia, who refused to sign portions of the licensing documents. LPA left a hard copy of this report and the Licensee Appeal Rights (LIC9058 01/16) with Licensee Rigoberto Garcia.