Routine inspection·June 2, 2023

Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct the facility's annual inspection. LPA met with Licensee, Dominica Oliva. During visit, LPA toured the facility with staff to include the kitchen, dining room, resident bedrooms, staff bedrooms, bathrooms, and backyard. Fire exits are free and clear of obstruction. Facility temperature maintained between 69 - 76 degrees Fahrenheit. Facility's kitchen observed in a sanitary condition. Facility maintains at least 2 days worth of perishable foods and 7 days worth of non-perishable foods. Refrigerator temperature maintained at 43 degrees Fahrenheit. Food stored in containers with lids and are labeled. Freezer temperature maintained at 0 degrees Fahrenheit. Chemical and sharp objects observed locked. Hand washing sign observed above the kitchen sink along with soap and paper towels. Facility's backyard observed free and clear of obstruction. LPA observed at least 10 pieces of long wooden planks with exposed nails on the wood. During visit, the wooden planks of wood was removed from the premises. LPA observed 6 out of 6 resident bedrooms equipped with proper furniture and supplies such as bedding, linens, adequate lighting, dressers, clothing, night stands, and a chair. Facility has an adequate amount of extra linens and towels to supply the residents. 1 out of 6 residents observed with a PRN of oxygen. Oxygen in use sign and facility emergency exit sketch observed posted on the door. LPA observed the physician's order for oxygen that was emailed to the Licensee. LPA advised to ensure the physician's order is maintained in the resident's file. Staff were provided training by a skilled professional on the oxygen equipment. SEE LIC812-C. 2 out of 2 bathrooms supplied with hand soap, paper towels and hand washing signs. Showers equipped with grab bars, non-slid mats, and shower chairs. Bathroom #1 hot water temperature maintained at 140 degrees F. During visit, staff lowered the hot water temperature. LPA observed the hot water temperature maintained at 130 degrees F. Licensee was advised. Facility has an emergency disaster plan. During visit, Licensee placed the emergency disaster plan in a visible area. It was observed 1 out of 2 facility emergency lighting in the hallway was non-operable. Facility was only equipped with 1 flash light that did not contain batteries. During visit, a staff member arrived with 6 flashlights and placed them in every residents bedroom. Facility has a complete first aid kit. Facility last conducted an emergency drill in January 2023. Licensee was advised to conduct a drill at least quarterly. Fire extinguisher last serviced on 05/03/2023. Facility is equipped with an operable carbon monoxide detector. LPA reviewed 4 out of 6 residents files contained an up-to-date physician's report, TB information, admission agreement, emergency contact form, personal rights form, consent forms, safeguard of personal properties, pre-admission, and appraisal needs and services plan. 4 out of 6 residents appraisal needs and services plan was more than 1 year old. Licensee was advised. During visit, Licensee began updating residents appraisal needs and services plan. LPA inspected 3 out of 6 residents centrally stored medications. Licensee was verbally advised to ensure the centrally stored medication records are filled out completely and accurately. LPA reviewed 3 staff files contained an up-to-date 1st Aid Certification, health screening form with TB information, and training in January - March 2022. Staff members present are fingerprint cleared and associated to the facility. LPA did not observe facility staff were provided training in 2023. Licensee was advised. 5 residents and 3 staff members were interviewed. Posters observed to include Ombudsman, if you see something say something, facility sketch, and COVID-19 poster. Deficiencies were cited per California Code of Regulations, Title 22. See LIC809-D. Advisory notes provided. This report was reviewed with Licensee, Dominica Oliva and a copy of the report and appeal rights were provided.