Routine inspection·February 20, 2024

LPA Audrey Jeung toured facility and grounds. Six residents are accommodated in private rooms with private bathrooms. There are 2 staff rooms--one with 1 bed and the other has 2 beds. Fenced backyard is level, landscaped, and partially paved; it is shared with Pacific Care Home II (3653 Pacific Blvd.)--also operated by J & I LLC. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is complete and maintained. Client files are reviewed, and medications are recorded on Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Rafael Jison (RCFE x 3/24) and Moddie Andaya are certified RCFE administrators that oversee facility operations, with assistance from Wilhelm Ick (x 3/24). As per legislation, effective 1/1/2015, the following information is posted: 1) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 2) CCLD Hotline information, per SB895. Signature page of Emergency Disaster Plan (LIC610) & proof of current liability insurance are given to LPA. The following licensing forms are requested to be updated and submitted to CCLD by 3/5/24. - Personnel Report (LIC500) is given to LPA. - Administrative Organization (LIC309) - Designation of Facility Responsibility (LIC308) Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages.