Routine inspection·August 23, 2023

Licensing Program Analysts (LPAs) Darlene Chavez and Kristin Kontilis conducted an unannounced required Annual Inspection at the facility. The facility is a one-story home which is licensed as a Residential Care Facility for the Elderly (RCFE) with a dementia diagnosis. The facility has been approved for a hospice waiver for 4 residents and has a fire clearance for 6 non-ambulatory residents, one of which can be a bedridden resident. Upon arrival, there were 5 residents in care and 2 staff on duty. One resident was away from the facility. Currently there are 6 residents residing in the facility with 1 resident on hospice. Administrator Timothy Pryko arrived at approximately 10:23 am. LPAs explained the purpose of the visit. Entrance interview conducted. A tour of the physical environment and accommodations were assessed, and the following was noted: LPAs observed the required posting of the complaint poster, bill of rights, Resident’s Rights, Non-discrimination statement, Infection Control Plan, and Emergency and Disaster Plan. LPAs inspected the facility for fire safety, personal accommodations, and food service. First aid kit was observed to be complete. The facility has 6 private bedrooms each with a private bathroom for 6 residents. Each resident’s room is furnished with overhead lights to provide sufficient lighting, a night stand, and a bed. The bathrooms have secure grab bars and no skid flooring. 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. Fire inspection was conducted on 6/15/2023. The carbon monoxide alarm and smoke alarms are in good working order. Medications are kept in a locked centrally stored cabinet. The living room and dining area are neat and clean. The facility maintains a comfortable temperature at 74.0 degrees Fahrenheit (F). Hallways, bedroom doors and walls are in good repair. Please continue to 809-C, Pg 2. According to the facility sketch used for the fire clearance, Exit #10 located on the east side of the facility is shown as a perimeter gate to exit the property in case of an emergency. Not shown on the facility sketch is a second perimeter gate on the east side leading from the backyard (south of facility). The second perimeter gate is locked from the north side making it inaccessible for residents/staff to exit in the case of an emergency. Noted on the gate is a sign that reads "Keep gate locked at all times." The facility sketch shows Exit #11 is a wrought iron gate with a combination lock located on the inside of the gate with signage stating "Keep gate locked at all times." LPAs observed the Emergency and Disaster drill logs do not specify the type of drill performed at the time of the drill. LPAs advised Administrator Pryko that all future drills need to state the specific drill being conducted or provide more specific information as to the description of what was covered during the drill. LPAs observed an oxygen tank in the facility with an "oxygen in use" sign on the door of Resident 1 (R1). There was no "oxygen in use" sign posted on the front door entering into the facility. The backyard has a covered patio with outdoor furniture. There is a cement fountain located in the backyard. The fountain is filled with water and rocks. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked private staff room is located in the main part of the house near the front entrance. From 10:33 am to 10:40 am, water temperatures were measured as 111.7 degrees Fahrenheit (F) in the kitchen, Bathroom #1 measured at 108.0 (F), and Bedroom #4 measured at 108.6 degrees (F). Residents participate at will in activities such as games, drawing, playing piano, scenic drives, and special celebrations. Staff records were reviewed. Staff training and required documents are in good order. All staff have received a criminal background check and have been properly associated to the facility. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted. A copy of this report was issued during the visit.