Routine inspection·September 28, 2023

Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 9:43 AM. to conduct an unannounced annual visit. LPA met the Administrator Brian Coday at the front door and was granted entry. 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 5 non-ambulatory residents in care. The facility has hospice waiver. 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 74 degrees. The facility consists of 3 resident bedrooms, and 2 bathrooms, living room, kitchen, 1 staff bedroom and backyard. The bedrooms are furnished with tv, 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 107.6 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the kitchen 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 pre-placement appraisal, identification and emergency information, physician’s report, resident appraisal, hospice documentation, client rights, and admissions agreement. (Continued on LIC809-C) (Continued from LIC809) 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 documented 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 08/01/23 at 9:30 AM. The facility has emergency supply of food and water. Items Discussed: Resident R2 and R5 do not have current physicians reports. Summary: Based on today visit, a deficiency is being cited. An exit interview was conducted and a copy of this report was provided to Administrator Brian Coday. LPA provided a copy of his Appeal Rights and his signature on this form acknowledges receipt of these rights.