Routine inspection·November 19, 2023

Unannounced annual visit made out to this facility on 11/19/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility live-in caregivers, Khin Htay and Alvin Galang, who were briefly interviewed at this time. This LPA requested that they go ahead and contact the facility designated Administrator to inform him/her that CCL was present at this time for an annual visit. The facility designated Administrator was unable to be present at today's annual visit but gave consent for the caregivers to sign all documents at this time. Current census was 5 residents. There was one resident under the care of hospice at this time according to statements made by the facility caregivers. This facility does have an approved hospice waiver to be able to accept and retain up to (3) hospice residents at any given time. Tour of this facility was conducted. A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time. Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time. A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times. Medication cabinet, located in the kitchen cabinets and drawers, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility staff at this time. A review of the facility Medication Administration Record and dispensing log was conducted. Medication cabinet was observed to be locked and made inaccessible to the residents at this time. Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents. A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the resident restrooms was conducted. Grab bars and non skid mats were reviewed to make sure that they were present and in good repair at this time. Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times. Laundry area, located in the garage, was observed to be unlocked but did not house any detergents, soaps, or bleach at this time. It was learned that all cleaning and laundry supplies were separately locked and made inaccessible to the residents at all times. Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. A tour of the garage area was conducted. Additional food storage units were observed to be present and in good repair at this time. First aid kit, located in kitchen area, was observed to be present and contained all of the required components at this time. Fire extinguisher was observed to have been annually inspected on 09/07/2023 by the local fire extinguisher company, So City Fire Protection, and in compliance at this time. A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted. A review of (5) resident files was conducted and noted on the LIC 858. A review of (4) resident staff files was conducted and noted on the LIC 859. The following forms and documents were requested to be updated and submitted into CCL in order to update this facility file: 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 representative at this time. Exit Interview