Routine inspection·October 1, 2023

Licensing Program Analyst (LPA) Christina Valerio and LPA Arielle Pascua arrived to the facility unannounced to conduct a facility annual inspection. LPAs met with facility staff Nancy Supetran, and explained the purpose of the visit. According to facility staff, the Licensee and Administrator is currently out of town. LPAs toured the physical plant to ensure compliance with Title 22 regulations. The facility is a three story building. The facility's first and second floor are the licensed areas of the home. LPAs toured the first floor and the second floor of the facility. The first floor appears to be utilized for storage, emergency supplies, and a private area for staff. According to facility staff, the licensee never utilized the bottom floor for residents. The second floor had 4 resident bedrooms, 2 resident bathrooms, a kitchen area, and dinning area. Resident bedrooms were observed to be fully furnished with a bed, night stand, chair, dresser, and closet space. In bedrooms 4, bedroom 2, bedroom 1, and the dinning area, LPAs observed pee pads on the top of chairs, bedding, and the floor of the bathroom. According to staff, this is used to prevent any bodily fluids and is changed every morning. LPAs observed the resident bathrooms. Hot water was measured at 117.0*degrees, which is within regulatory range of 105-120*F. A fully charged fire extinguisher with an annual inspection of 05/09/2022, carbon monoxide detector, and air conditioning was observed to be in working condition. The kitchen area was observed to be locked. According to a phone conversation with Licensee Renelee So and facility staff Nancy, the facility has always had the kitchen locked, which Golden Gate Regional Center has been in agreement with implementing this. LPAs informed the licensee that the department does not have an approved waiver to have the kitchen/food items locked and inaccessible to residents in care. Medications, cleaning supplies, and sharps were observed to be locked and inaccessible to residents in care. Continues on LIC 809 -D... ...Continued from LIC 809 LPAs reviewed 5 resident files for Resident 1 (R1) - Resident 5 (R5). Resident files were observed to be incomplete. R1 - R5's file did not have an updated Appraisal, LIC 602, or Individual Program Plan (IPP) on file. R2's LIC 602 had a diagnosis of dementia. According to the Regional Office File Review, the facility does not have an approved Dementia Care Plan nor are they licensed to serve individuals with dementia. Training related to dementia care were not observed in the staff training section. The facility's last Fire Drill was conducted with residents during September of 2023. An updated surety bond policy was observed. LPAs reviewed 3 staff files. Two staff observed working in the facility were observed to be fingerprinted and cleared. Staff had an up to date First Aid Certificate. Licensee Renelee and Facility staff Nancy stated that the administrator changed a few years ago. Licensee Renelee So is the designated administrator. Administrator Certificate #6011479740 Expiration 03/20/2024. TA was provided to facility staff. The licensee will send updated information to change Administrator to the Regional Office. LPA requested the following documentation be sent to the Regional Office: Control of Property LIC 308 - Designation of Facility Responsibility LIC 999 - Facility Sketch Liability Insurance Qualifications of Administrator Surety Bond LIC 500 LIC 601D - Emergency Disaster Plan Per California Code of Regulations (CCR) - Title 22, Division 6, deficiencies are being cited today on the attached LIC 809 - D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held, and a copy of the report was provided to facility staff Nancy.