Routine inspection·October 27, 2021

On 10/27/2021 Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual Inspection at 4:15pm with Licensee Edgar Espiritu. Administrator Ruth Banga arrived shortly after. LPA was allowed entry into the facility that is licensed to serve a total capacity of 15 and today's census is 13. Licensee accompanied LPA on facility tour. Four of four staff observed on site with criminal record clearance in Licensing Information System. One of one staff observed cleared but not associated, observed transfer request submitted, LPA to process association. LPA observed Administrator Certificate expires on 8/29/2022 and Licensee's Certificate expires on 3/20/2023. LPA interacted with a random number of residents during this visit and observed clients. The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed kitchen, restrooms, bedrooms, and common living areas. LPA observed paint and items not in use or good repair stored in backyard. LPA observed toxins, knives, centrally store medications stored inaccessible to residents. 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 112*F within regulatory range of is not less than 105*F and not more than 120*F. Kitchen hot water measured at 127*F not accessible to residents. The first aid kit was found in compliance containing at least the following: a current edition of an approved first aid manual, but containing sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution. LPA observed COVID precautions signs posted, restrooms stocked with paper towels, hand soap, touchless covered trash cans, and posted hand washing signs. 30 day supply of PPE stored on site. Staff one (S1) stated common surfaces are disinfected daily and in between use. LPA observed hand sanitizer available throughout the facility. Observed medications not administered per physician's orders in that Resident one (R1) PRN narcotic administration 3 times daily did not match medications count, 2 pills missing from start date beginning quantity of 42 and PRN log not documented administrations. LPA observed fire extinguisher last inspected on 7/19/2021, fire suppression system last inspected on 2/4/2020, last sticker placed in 11/2019 on fire suppression system. Observed 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 food sitting on the floor in kitchen and food debris in refrigerator not clean. The facility last conducted fire drill on 6/20/2021. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Administrative Responsibility LIC308 Personnel Report LIC500 Administrator Certificate Emergency Disaster Plan LIC610E Liability Insurance Health Screening Report-Facility Personnel LIC503 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.