Routine inspection·February 27, 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 Caregivers Jimmy Merino and Jamela Reyes Magulod. The facility is licensed for a maximum capacity of 6 residents, 2 of which may be non-ambulatory in bedroom #4. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 5 residents, all of which were non-ambulatory, which puts the facility over the approved capacity for non-ambulatory residents. LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Nguyen N Le 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, staff rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed near or on the premises. According to Jamela Reyes Magulod, 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. The facility’s water temperature was measured at 106.0 degrees Fahrenheit in a private resident bathroom and 112.3 degrees Fahrenheit in a common bathroom. The facility’s internal temperature was measured at 74 degrees Fahrenheit. LPA observed cleaning and laundry chemicals stored in unlocked cabinets in the laundry room. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and label. 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 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit. LPA observed linens and hygiene products provided to the clients 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. Continued on LIC809-C page… LPA reviewed multiple resident and staff records. Review of resident records revealed that all 5 residents are receiving hospice services and LPA observation of resident rooms and record review revealed that 4 of 5 residents, Resident 1 through Resident 4, did not have a doctors order for bed rails. [Caregiver was provided with an LIC811 Confidential Names list to identify R1-R4] Each resident record 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 over-capacity, unlocked chemicals, and postural supports are cited per CA Code of Regulations Title 22 and noted on the attached LIC809-D pages. Additionally, civil penalties are being assessed for over-capacity and are noted on the attached LIC421IM in the amount of $500. An exit interview was conducted with Licensee Hong Hanh Le Doa via telephone and Caregiver Jamela Reyes Magulod, whose signature below confirms receipt of a copy of this report, the LIC811, the LIC421IM, and the Licensee Appeal Rights (LIC9058 3/22).