Routine inspection·May 20, 2021

Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 5/20/21 at 11:30am. LPA met with Licensee Marivic Teano Chua and stated the purpose of today’s visit. LPA contacted Licensee prior to today's visit for COVID screening. LPA was allowed entry into the facility and was accompanied by Licensee throughout the inspection tour that is licensed to serve a total capacity of 26 clients today's census is 25. LPA observed four of four staff associated and cleared in Licensing Information System. LPA observed Administrator Certificate expires on 11/4/2022. LPA interacted with a random number of residents during this visit engaging in activities and dining maintaining social distancing and practicing COVID precautionary measures. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed resident rooms with required furniture and lighting, common dining and living areas, kitchen, and storage areas. The temperature inside the facility was measured at 69*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 106*F which is within regulatory range of 105*F and 120*F. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA reviewed medications against MAR's, medications are packed by pharmacy administered as physician's orders. One resident refusal of medications documented on MAR. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. Continued on 809 C. Continued from 809. LPA observed window missing screen, broken patio table, loose bricks, shed without door, two cracked windows, and stored items not in working order on property grounds accessible to residents in care. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed call system not working and Administrator stated it was not in working order. Facility handles P & I monies, LPA observed the log is maintained correctly and there is no commingling of funds. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed emergency food supplies. The kitchen was observed clean and in good repair and refrigeration and freezer was within regulatory temperature range. LPA observed chemicals and kitchen knives locked and inaccessible to residents. Upon a file review the following items were discussed to be submitted with any changes annually to LPA by 6/4/2021: Administrative Organization LIC309 Designation of Administrative Responsibility LIC308 Personnel Report LIC500 Affidavit Regarding Client/Resident Cash Resources LIC400 Emergency Disaster Plan LIC610E Health Screening Report- Facility Personnel LIC503 In-service Training Program First aid/CPR certificates Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given