Routine inspection·March 13, 2025

On March 13, 2025, at 08:45 AM, the Licensing Program Analyst (LPA) Kiran Jain arrived unannounced at the facility to conduct a Required 1-Year Annual inspection. The LPA met with the Administrator, Elma Pacursa, and disclosed the purpose of the inspection. The Administrator informed the LPA that the facility had (5) residents in care and (3) staff members present at the time. The Licensee, Helen Ng arrived shortly after. At 9:23 AM, the LPA initiated a walk-through of the facility, accompanied by the Administrator. LPA inspected the kitchen and found it clean, with no food preparation and cooking in progress at the time. The appliances were checked and observed to be in working order. The LPA inspected a locked cabinet containing knives and sharp objects. The refrigerator and pantry cabinets were inspected, and sufficient supplies of fresh perishable food for (2) days and nonperishable staples for (7) days were observed. No expired food or stored medications were noted. LPA inspected the dining area adjacent to the kitchen and found it clean. The dining table and chairs were observed to accommodate the residents, and all the furniture was in good repair. (4) residents were observed eating breakfast. LPA inspected the fire extinguisher mounted on the wall in the kitchen and found it fully charged, with the last service tag dated 06/04/2024. The Administrator tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. Additional smoke and carbon monoxide detectors were observed in all bedrooms and common areas of the facility during the visit. LPA inspected the living room and observed it clean, with all furniture in good repair. There was a sofa set and a television in the living room. (1) resident was observed watching TV. Continued on LIC809-C There were (6) bedrooms and (2½) bathrooms designated for residents' use. All (6) resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. All exit doors had Auditory alarms for notification. LPA inspected (2½) bathrooms and found them clean, sanitary, and in good working condition. The bathrooms contained soap, grab bars, paper towels, a trash can, a shower chair, and non-slip flooring. The hot water temperature at the sink faucet measured 118.7°F in bathroom #1 and 149.8°F in bathroom #2. Bathroom closets were observed to contain clean linens and towels for residents’ use. LPA inspected the garage and found it clean. A break room for staff with sofa was observed. A washer, a dryer, a refrigerator, a freezer containing additional food supplies, wheelchairs, mattresses, a cabinet with detergents, disinfectants, and cleaning supplies, and storage cabinets with incontinence supplies, and paper products were observed. LPA toured the backyard area and found ramps and passageways in good condition, clear of obstructions, with no blocking or tripping hazards. The backyard has a set of a patio table, chairs, and shaded areas for resident use. No bodies of water and no tripping hazards were noted. LPA reviewed (5) staff personnel records and (5) resident records. The LPA observed that 4 of 5 residents with dementia did not receive an annual Physician assessment and did not have Appraisal Needs and Services Plan. LPA observed that 5 of 5 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 5 of 5 staff members were associated with the facility. LPA observed a locked centrally stored medication cabinet inside the kitchen area. Medications were organized in separate bins for each resident. All medication bottles were properly labeled. Centrally Stored Medication Records were reviewed and found to be complete. LPA inspected the first aid kit and found it fully stocked. Emergency Drill Logs were reviewed, and it was observed that Emergency Disaster Drills were conducted quarterly, with the most recent drill completed on 01/05/2025. Continued on LIC809-C The following updated forms are requested to be submitted to CCLD by 03/20/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance Updated Facility Sketch (Floor Plan) Administrator Certificate(s) The deficiencies are being cited based on LPA observations, records reviewed, and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted with the Licensee. A copy of this report was left with the Licensee, Helen Ng, whose signature on this form confirms receipt of the report.