Routine inspection·August 17, 2021

On 8/17/2021 Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual inspection at 10:05am and met with Staff one (S1). LPA unable to contact Licensee for COVID screening prior to entry. LPA COVID screened upon entry to the facility. LPA was allowed entry into the facility that is licensed to serve a total capacity of 14 residents. Today's census is 11 of which 1 is Hospice. Five of five staff observed on site with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 9/26/2022. Staff two (S2) arrived and accompanied LPA on facility tour. Administrator arrived and met with LPA after facility tour. LPA interacted with a random number of residents during this visit and observed residents. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed two facilities on two properties housing residents. LPA observed kitchen, garage, restrooms, bedrooms, and common living areas to be clean and in good repair. LPA observed five of eight resident rooms without required furnishings including chair, chest of drawers, and night stands. S2 stated they have just purchased some night stands. LPA observed a variety of missing items in the various rooms. The temperature inside the facility was measured at 70*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 114.1*F and 111.7*F within regulatory range of is not less than 105*F and not more than 120*F. LPA observed the centrally stored medications, toxins, and knives stored in the locked garage office to be locked inaccessible to residents. The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. Continued on 809 C. LPA observed fire extinguishers, smoke and carbon monoxide detectors, central heating and air in the facility. 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 COVID precautions signs posted, restrooms stocked with paper towels, hand soap and touchless covered trash cans, no hand washing signs observed. Licensee stated he would put them up at sinks. Licensee stated 30 day supply of PPE stored is stored on site in his garage at home. LPA observed bacterial analysis of private water supply not conducted annually. Licensee stated all residents and staff are drinking water from water bottles at this time. The facility has an approved Mitigation Plan. Upon a file review the following items were discussed to be submitted to LPA by 8/30/2021: Licensing fees Administrative Organization LIC309 Designation of Administrative Responsibility LIC308 Personnel Report LIC500 Facility Floor Plan/Plot Plan LIC999 Qualifications of Administrator/Facility Manager Control of Property (2) Bacteriological Analysis of Private Water Supply 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 and 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.