Routine inspection·June 3, 2021

On 06/03/2021 at 8:10am, Licensing Program Analyst (LPA) Ashley Boothe spoke with Administrator, Elizabeth Abesa regarding facility risk assessment questions. Administrator confirmed no staff or clients have experienced symptoms within the last 10 days. At 12:15pm LPA and Licensing Program Manager (LPM) LPM Liza King arrived unannounced to conduct a required 1-year Annual inspection. LPA and LPM met with Administrator, Elizabeth Abesa and explained the purpose of today’s inspection. LPA and LPM was allowed entry into the facility that is licensed to serve a total capacity of 15 residents of which 2 are non ambulatory and 0 Hospice in compliance with fire clearance and licensure. Three of three staff observed with criminal record clearance and associated in Licensing Information System. LPA observed Administrator Certificate expires on 10/26/2021. LPA interacted with a random number of residents during this visit. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed property, resident bedrooms, restrooms, common area, dining room, kitchen. LPA observed all required furniture in resident rooms and new flooring in good repair. The temperature inside the facility was measured at 76 *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 106.7 *F which is not less than 105 *F and not more than 120*F. LPA observed the centrally stored medications, knives, and chemicals stored in locked kitchen area inaccessible to residents. Administrator stated residents are supervised during meal times in the attach dining room. 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 missing antiseptic solution. LPA observed a fire extinguisher inspected on 2/5/2021 and 5 year inspection on suppression system conducted in May 2020, 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 the freezer and refrigerator with food drippings and debris with staff food comingled and unlabeled. LPA observed missing window screens in resident rooms, common area, and kitchen, two hoses unravelled on the outdoor walkway residents use, barbed wire on back property fence, and shower curtain with mold. LPM provided recommendations to Administrator on COVID Mitigation Plan report. Updated Mitigation Plan to be submitted to LPA by 6/7/2021. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Administrative Responsibility LIC308 Personnel Report LIC500 Facility Floor Plan/Plot Plan LIC999 Administrator Certificate Emergency Disaster Plan LIC610E First aid/CPR certificates Liability Insurance 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.