Routine inspection·April 9, 2025

On April 09, 2025, at 08:40 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, Becky Bi, and disclosed the purpose of the inspection. The Administrator informed the LPA that the facility had (5) residents in care and (2) staff members present at the time. At 9:28 AM, the LPA initiated a walk-through of the facility, accompanied by the Administrator. LPA inspected the kitchen and found it clean, with breakfast 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. Three (3) residents were observed eating breakfast. 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. One (1) resident was observed sitting on the sofa and drinking coffee. LPA inspected the fire extinguisher mounted on the wall in the living and found it fully charged, with the last service tag dated 01/21/2025. Continued on LIC809-C The Administrator tested the smoke and carbon monoxide detector located in the living room 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. There were six (6) bedrooms and four (4) 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. Storage closets with incontinence supplies were observed in every room. LPA inspected four (4) full 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. At 9:46 AM, the hot water temperature at the sink faucet measured 140.5°F in bathroom #1 and 142.2°F in bathroom #2. The hallway closets were observed to contain clean linens and towels for residents’ use. LPA inspected the garage and found it clean. A washer, a dryer, a refrigerator, a freezer containing additional food supplies, a cabinet with detergents, disinfectants, and cleaning supplies 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 were noted. LPA inspected (1) storage shed and observed wheelchairs, walkers, and furniture items in the shed. LPA reviewed three (3) staff personnel records and five (5) resident records. At, 10:58 AM, The LPA observed that 1 of 5 residents with MCI had last annual Physician assessment done on 07-10-2015. LPA observed that 3 of 3 staff members had LIC 508 Criminal Record Statements and LIC 503 Health Screening and confirmed that 3 of 3 staff members were associated with the facility. At 11:34 AM, the LPA observed a locked centrally stored medication cabinet located inside the locked cabinets in the kitchen. Medications were organized in separate bins for each resident. 3 of 5 resident’s medication prescription names, numbers and date filled were not entered correctly in the Centrally Stored Medication Records (CSMR). 3 of 5 resident’s prescription medication labels were altered with the handwritten notes on it. LPA inspected the first aid kit and found it fully stocked. Continued on LIC809-C At 11:48 AM, the LPA reviewed Emergency Drill Logs and observed Emergency Disaster Drills were not conducted quarterly, with the most recent drill completed on 04/06/2019. The following updated forms are requested to be submitted to CCLD by 04/16/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility Certificate of Liability Insurance 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, and Plans of Correction were reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and provided to the Administrator, Becky Bi, whose signature on this form confirms receipt of these documents.