Routine inspection·December 7, 2022

Unannounced annual visit made out to this facility on 12/07/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Pedro Pancho. Brief interview was conducted with the facility designated Administrator at this time. Current census was (2) residents. It was learned that there was one resident under the care of hospice at this time. This facility does have a waiver to accept and retain up to (6) residents under hospice care. Tour of the facility was conducted. Kitchen area was toured. Cabinets and drawers were reviewed to make sure that there was a sufficient supply of plates, silverware, and items necessary to meet the needs of the residents at this time. A review of the facility food supply was conducted to make sure that there was an adequate 2-day perishable and 7-day nonperishable amounts at all times. Pantry area was toured. Cleaning supplies and agents were observed to be present under the kitchen sink cabinet and were locked and made inaccessible to the residents at this time. Dining area, living area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time. Fire extinguisher, located hanging in facility entry way, was observed to have been purchased on 11/13/2022 from The Home Depot at this time. A tour of the facility resident rooms was conducted. Bedroom furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the facility resident restrooms was conducted. Grab bars and non skid mats were observed to be in place and able to serve the needs of the residents at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at all times. Laundry area was toured. Cabinets housing detergents, bleach, and all other laundry supplies were observed to be behind a door that could be locked to make these items inaccessible to the residents at all times. A tour of the facility garage area was conducted. Cabinets housing additional items for resident use were reviewed. Additional linens, seasonal supplies, and cleaning agents were observed to be stored behind a door leading into this area that was locked to make it inaccessible to the residents at this time. Linen closet was observed to contain the necessary supplies and items in order to meet the needs of the residents at this time. Medication cabinet, located in entry way cabinet, was reviewed. Policies and procedures for handling, dispensing, and documentation of the resident medications were reviewed with the facility designated Administrator at this time. A review of the facility medication administration record (MAR) was conducted. First aid kit was present and observed to contain all of the required components at this time. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gate, and exits was conducted. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal rights were printed and a copy was given to the facility designated Administrator Pedro Pancho at this time. Exit Interview