Routine inspection·March 14, 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 Caregiver Leonor Gaya. The facility is licensed for a maximum capacity of 6 residents, 5 of which may be non-ambulatory. The facility has a waiver for 3 hospice residents. During today’s visit, the facility had a census of 6 residents, all of which were non-ambulatory. The facility also had 4 residents receiving hospice services. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Rafael Gamab and their certificate was valid and current. During today’s visit, 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. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 134.4 degrees Fahrenheit in a common bathroom. Caregiver Leonor Gaya turned the water heater down and the water temperature was measured at 118.2 degrees Fahrenheit in the same bathroom. The facility’s internal temperature was measured at 73 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Leonor Gaya, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. LPA observed pillboxes for 6 residents which contained the medication doses for the noon, pm, and bedtime medication passes for all 6 residents. 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 45 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 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. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. 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 Administrator 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 fire clearance, hospice waivers, medications, and hot water temperature were cited per California Code of Regulations Title 22 and noted on the attached LIC809-D pages. Additionally, a civil penalty for the fire clearance in the amount of $500 is being issued on an LIC421IM. An exit interview was conducted with House Manager Lauren di Lantis via phone and Caregiver Leonor Gaya, whose signature below confirms receipt of a copy of this report, the LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).