Routine inspection·January 19, 2022

Licensing Program Analyst (LPA) Ruth Wallace arrived unannounced to conduct Required Annual/Random Inspection. LPA contacted Licensee who designated staff one (S1) who arrived at the facility shortly after. LPA 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 5 and 1 hospice residents. 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. S1 stated they are planning a junk removal pick up for items stored in the garage. The hot water was measured at 108.5 *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. LPA observed fire extinguishers expire 6/3/2022 and central heating and air in the facility. Seven smoke and carbon monoxide detectors in working order. 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 inside, Observed restrooms stocked with hand soap, hand washing signs posted, touchless covered trash cans, and paper towels in dispenser. LPA observed 30 day supply of PPE stored. Continued on 809-C Continued from 809 Upon a file review the following items were discussed to be submitted by 02/09/22: Designation of Administrative Responsibility LIC308 Personnel Report LIC500 Liability Insurance Administrator Certificate Emergency Disaster Plan LIC610-E Facility Sketch Job Descriptions Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 809-D 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.