Routine inspection·October 10, 2023

Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 10:33 am. to conduct an unannounced annual visit. LPA met the Caregiver Chima Umolu at the front door and was granted entry. LPA met with Caregiver Juan Carlo Ponce de Leon regarding the visit. 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 12 non-ambulatory residents of which 4 may be bedridden, with 7 non-ambulatory and 3 bedridden resident in care. 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 71 degrees. The facility consists of 7 resident bedrooms, and 2 bathrooms, living room, kitchen, 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 109 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the laundry room and inaccessible to the resident. The facility and has a current fire clearance for the facility, 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 identification and emergency information, physician’s report, resident appraisal, additional assessments, and admissions agreement for 4 residents in care. (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, however no records due to no residents in care, however previous resident records were found, 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 06/11/23. The facility has emergency supply of food and water. Items of Discussion: Physician’s reports are missing for residents R2, R3, R4, R6, R7, and R8. Residents R4 and R6 are missing identification and emergency information, physician’s reports, physician’s orders, pre-assessments, and admissions agreements. The facility currently does not have a resident roster or LIC9020. Summary: Deficiencies are being cited per Title 22, Div. 6, Chap 8 and listed on LIC 809-D. An exit interview was conducted, Appeal Rights (LIC 9098) along with a copy of this report was provided to Caregiver Juan Carlo Ponce de Leon and his signature on this form confirms receipt of these rights.