Routine inspection·September 1, 2021

On 9/1/2021 at 1:15pm, Licensing Program Analyst (LPA) arrived unannounced to conduct a Required 1-year Annual Inspection. LPA contacted Licensee who designated staff one (S1) who arrived at the facility shortly after. LPA's was allowed entry into the facility that is licensed to serve a total capacity of 6 residents, hospice waiver for two. Today's census is 6 and 0 hospice residents. Two of two staff observed with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 12/16/2021. 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 kitchen, laundry room, garage, restrooms, bedrooms, and common living areas. LPA observed items stored not in use in the garage, microwave not working and kitchen cabinets with built up grease and food splatter, and floors in second resident room peeling not in good repair. S1 stated they are planning a junk removal pick up for items stored in the garage. The temperature inside the facility was measured at 75*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 110 *F which is not less than 105 *F and not more than 120*F. LPA observed the centrally stored medications, knives, laundry and garage area to be locked inaccessible to residents. 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. LPA observed fire extinguisher last inspected 6/3/2021 and central heating and air in the facility. Four of seven smoke and carbon monoxide detectors in working order and three with out working batteries. S1 inspected and replaced all batteries during today's visit. 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 did not observed COVID precautions signs posted inside, Observed restrooms stocked with hand soap, hand washing signs posted, touchless covered trash cans, and paper towels not in dispenser. LPA observed less than 30 day supply of PPE stored. LPA to order PPE from the Regional Office during next office day and coordinate pick up or delivery. LPA observed R1 with Dementia last updated assessment in 1/2020. Upon a file review the following items were discussed to be submitted by 9/17/2021: Criminal Record Clearances LIS536 Administrative Organization LIC309 Designation of Administrative Responsibility LIC308 Personnel Report LIC500 Liability Insurance Administrator Certificate Emergency Disaster Plan LIC610E First aid/CPR certificates Per California Code of Regulations (CCRs) - Title 22, Division 6, 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.