Routine inspection·November 22, 2023

Unannounced annual visit made out to this facility on 11/22/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Sheram Amparo, who was requested by this LPA to go ahead and contact the facility designated Administrator Joyce Mabunga to inform her that CCL was present at this time to conduct the annual visit. The facility designated Administrator Joyce Mabunga arrived shortly thereafter and was briefly interviewed at this time. Current census was 5 residents. It was learned that there was a resident under the care of hospice at this time. This facility does have a hospice waiver for (4) residents at this time. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Joyce Mabunga. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 07/24/2024 with certificate # 6056435740. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe an additional food storage unit which was present and functional at this time in the garage area. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet, located in the hallway closet, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrator at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. Garage area was toured. This area housed additional furniture and supplies for the facility residents. Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time. Fire extinguisher, located in facility kitchen area, was observed to have been annually reviewed on 08/16/2023 by the local fire extinguisher company, Armor Fire Extinguisher, and in compliance at this time. Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted. A review of (5) facility resident records was conducted and noted on the following LIC 858 form. A review of (4) facility staff records was conducted and noted on the following LIC 859 form. The following forms and documents were requested to be updated and submitted into CCL: 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 at this time. Exit Interview