Routine inspection·October 8, 2024

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced Inspection of the above-named facility. Kelly Burley, Licensing Program Manager accompanied LPA during the visit. LPM and LPA were greeted by Staff 1 (S1). Alex Polunets arrived approximately 10:12 am. LPA explained the purpose of the visit. At the time of arrival, there was one staff on duty and six residents in care. The facility is a Residential Care Facility for the Elderly (RCFE) The facility accepts residents with a dementia diagnosis; has a hospice care waiver for four residents; and a fire clearance for six non-ambulatory residents, of which two (2) can be bedridden. Currently there are three (3) residents on hospice residing in the facility. Entrance interview conducted. The facility is a one-story facility located in a residential area. LPM and LPA observed the required posting of the complaint poster and Resident’s Rights. The one-story facility was inspected for fire safety, personal accommodations, and food service. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. LPA observed the fire inspection was last conducted on 8/28/2024. LPA observed eight smoke alarms and 1 carbon monoxide detector were in good working order. Entrance into the facility leads into the common area and the dining area. The kitchen cabinets, refrigerator, stove, and counters are clean. The facility is sufficiently stocked with at least two days of perishables and seven days of non-perishables. Snacks and beverages are available for residents in care upon request. Sharps are kept in the laundry room. There are six private bedrooms and one extra bedroom. Bedrooms #5 and #7 have a private bathroom. There is one bathroom off the facility hallway available to all residents in care. Cleaning agents are kept in a cabinet in the garage. Medications are kept in two cabinets in the facility’s laundry room. First aid supplies were observed to be in good order. Please continue to 809-C, Pg 2. Residents participate at will in music activities, puzzles, and games. From 9:31 AM through 11:35 AM, LPA intermittently interviewed residents in care. From 1:00 PM through 1:10 PM, LPM and LPA interviewed Administrator Alex Polunets. The backyard has a paved patio with a table and chairs with an umbrella, sitting area, and raised garden areas. The backyard is conducive for outdoor visitations. The front yard has garden areas and is access into the main entrance of the facility. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The following deficiencies were observed: <At 9:33 AM, upon entering the facility, LPM and LPA observed S1 on duty providing care to six residents. LPM and LPA determined that S1 has a background clearance however is not properly associated to the facility. <At 9:37 AM, LPM observed a tray on the kitchen counter with five empty medication cups and one medication cup with 4 white medications, one yellow medication and one red medication. <At 9:37 AM, LPM observed the front right stove burner on a "low-medium" flame visibly burning and unattended by staff. A verbal warning was discussed with Administrator Alex Polunets. <At 10:29 AM, LPA noted the residents' bathroom off the hallway water temperature was measured at 127.0 degrees Fahrenheit (F). LPA noted that at the time the water temperature was measured, the temperature continued to rise. <At 10:36 AM, LPA noted the private shared bathroom between Bedrooms #5 and #7, the water temperature was measured at 128.3 degrees F. LPA noted that at the time the water temperature was measured, the temperature continued to rise. <At 11:20 AM, LPM reviewed medication records for two residents and noted facility's Centrally Stored Medication Record is not properly completed. Due to time restraints, LPA will return at a later date to continue the inspection. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights issued at the time of the visit.