Routine inspection·October 19, 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 Licensee Philip Butzen. The facility is licensed for a maximum capacity of 6 residents, all of which may be bedridden. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 4 residents, 2 of which were bedridden and receiving hospice services, 1 was non-ambulatory, and 1 was 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 Lyndon Derafera and their certificate was valid and current. 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. The facility has a swimming pool on the premises that is located down a flight of stairs. During today's visit, LPA observed two sections of the fence surrounding the pool had been removed, resulting in the swimming pool being unsecured. Per the Licensee, the fence had been removed approximately 3 months ago. A deficiency and an immediate civil penalty of $500 was assessed during today's visit. According to the Licensee, 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. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. Continued on LIC809-C page... LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. 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. Due to time constraints, the LPA was unable to complete the Required-1 year inspection during today's visit and an annual continuation will be conducted at a later date. The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC809-D page. The $500 civil penalty was noted on the LIC421IM form. An exit interview was conducted with Licensee Philip Butzen, whose signature below confirms receipt of a copy of this report, the LIC421IM, and the Licensee Appeal Rights (LIC9058 01/16).