Routine inspection·February 24, 2025

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Mary Phets. LPA then met with Licensee and Administrator Joseph Alvela, who arrived later during the visit. According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom all may be ambulatory or non-ambulatory, and one (1) may be bedridden (in Bedroom #3 only). According to LIC602 Physician’s Reports, staff interviews, and LPA observation: During this annual inspection, there were a total of five (5) residents in care [Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), Resident #5 (R5)], of whom all were non-ambulatory, per their respective doctors. [See LIC811 Confidential Names list pages for a description of select person identifiers used in this report.] The facility’s license did not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present. During this inspection, LPA interviewed all residents and multiple staff. LPA reviewed the care records for all residents and the personnel and training files for all current staff. LPA also toured the interior and exterior of the facility and inspected all common areas and bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] The facility’s ambient internal temperature was complaint at 79 F. Hot water at taps accessible to residents were also compliant in temperature: Kitchen Sink was 108.5 F, Bathroom #1 Sink was 107.2 F, and Bathroom #2 Sink was 108.1 F. The facility’s refrigerators and freezers, which were used to preserve perishable foods, were also all compliant in temperature. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. No pools or bodies of water observed on the premises. The facility's fireplace was screened. There were no open-faced heaters accessible to residents. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Per the Licensee, no firearms or ammunition were kept at the facility. Licensee presented proof of current business liability insurance. According to their respective LIC602 Physician’s Reports: R1, R2, and R3 were diagnosed with Dementia, while R4 and R5 were diagnosed with Mild Cognitive Impairment (MCI). Even so, R4 was determined by their doctor to be at risk if “allowed direct access to personal grooming and hygiene items.” Per the doctors, none of R1 through R5 could safely store their own prescription medications. Interviews of facility staff showed all residents required staff assistance with storing and taking their medications. Also, per their doctors, none of R1 through R5 would be safe if they left the facility unassisted. During today’s visit, LPA observed a non-locking drawer in the facility’s kitchen, which contained four (4) bottles of prescription laxative medications and one (1) bottle of cough medicine, all belonging to residents. LPA was able to take out these bottles with staff noticing. [LPA subsequently directed staff to relocate the medicine bottles to a different cabinet that was able to be locked.] Left out in the kitchen was one (1) unattended bottle of dishwashing soap; this needed to be locked when not in active use by staff because of what R4’s doctor wrote about them on their LIC602 (see above). Also, inside the shower of one the facility’s two shared bathrooms was one (1) unattended spray bottle containing a cleaning chemical; this toxin needed to be secured from all residents. LPA was able to take and manipulate these bottles without staff noticing. [LPA subsequently directed staff to relocate these bottles to locked cabinets.] [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Licensee had previously installed auditory door chime devices (i.e., “staff alert devices”) on each of its exterior exit doors, as required when caring for persons diagnosed with Dementia. However, during today’s visit, LPA observed that facility staff had manually switched the devices “Off,” rendering them inoperable on six (6) of eight (8) exterior exit doors. [LPA manually switched these devices back to the “On” position and verified they were working.] During review of client records, LPA observed, and manager interview confirmed: Licensee did not maintain current Primary Care Physician (PCP) name, address, and contact information for R2, R3, and R4. Licensee also did not maintain current designated Dentist name, address, and contact information for R1 through R5. Also, Licensee did not maintain a record of body weights for R1 through R5. (Regulation required Licensee to “regularly observe” clients for changes in physical condition, to include “unusual weight gains or losses.”) During review of personnel/training records, LPA observed, and manager interview confirmed: Licensee did not have proof that S1 through S3 had received training on Personal Protective Equipment (PPE) within the last year, as was required. Licensee also did not have proof of completion of disaster drills within the last calendar year. (Regulation required Licensee to drill each shift at least once per quarter). Six (6) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued Technical Assistance (TA) regarding refresher training for staff on California Mandated Reporting requirements (refer to the LIC9102-TA page). An exit interview was conducted with Licensee and Administrator Joseph Alvela, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today's visit.