Routine inspection·July 12, 2022

Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection visit to the above-named facility. LPA arrived at 1:25 pm was greeted by Staff 1 (S1). Administrator Victoria Andreichenko arrived at approximately 1:45 pm. Valentyna Polunets, Co-Administrator arrived at approximately 1:55 pm. At the time of arrival, there were 5 residents in care and 1 staff on duty. A Mitigation Plan has been submitted to CCLD. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a dementia diagnosis. Entrance interview conducted: A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service. First aid kits were observed to be complete. Entrance interview conducted. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There is one fire extinguisher on the premises last serviced on 7/23/2021. There is a total of one dual smoke/carbon monoxide alarm and six smoke alarms throughout the facility all in good working order. Snacks and beverages are available for residents in care upon request. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Cleaning agents and the toxic chemicals are kept in a locked garage. Medications are kept in a locked centrally stored cabinet. Sharps are kept in a locked cabinet in the kitchen. The backyard has a covered patio with outdoor furniture, a gazebo, paved walkways, and a locked shed. The front yard is conducive for outdoor for outdoor visitation. The front yard has paved walkways and garden areas. LPA observed a vase approximately 3 feet tall and 18 inches in diameter with standing water located in the garden area of the front entrance into the facility. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The living room and dining area are neat and clean. The facility maintains a comfortable room temperature measured at 1:45 pm. Hallways, bedroom doors and walls are in good repair. The facility has six (6) bedrooms for a capacity of six residents. Bedroom #1 has a private bathroom. There three bathrooms available for residents located off the hallways of the facility. All of the bedrooms are furnished with lights and nightstand lamps to provide sufficient lighting. There are two residents currently on hospice. Hospice information was reviewed for Resident 1 (R1) and Resident 2 (R2). Upon record review, LPA determined that CCL did not receive a hospice notification for R1. Upon record review and interviews conducted, hospice notification for R1 was submitted to CCL with no identifying information including but not limited to facility name, facility number, and facility address. All persons associated with the facility have a criminal background clearance. 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. Due to technical difficulties, report was sent to Administrator for signature. Copy of report and appeal rights issued via email.