Routine inspection·January 9, 2025

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Wennie R. Concepcion. During the visit, LPA observed 1 residents and 2 staff. LPA explained the purpose of the visit. LPA entered the home at 10:33am, and was welcomed by staff S1. As LPA was midway thru the living room, staff S2 entered living room, coming from staff rooms/ bedroom #3 area. Staff S2 was only wearing grey underwear. S2 then entered the living room and began to get changed in the living room. ADM stated S2 must have just washed his/her cloths and that this usually doesn't happen. ADM acknowledged S2 has his/her own bedroom, and he/she should have gotten changed in his/her bedroom. ADM acknowledged S2 entering the living room with just his/her underwear would create an uncomfortable environment for visitors and residents in care. ADM stated staff S2 is a reliever staff. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 3 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. While touring the backyard, LPA observed an unattended torch gun, with its propane tank attached. (Photograph was taken.) ADM stated the cooking torch gun was just used last night and the other night. ADM stated it is used to brown the meat. ADM stored the torch gun during visit, inside locked storage shed. While touring the backyard, LPA observed a stack of boxes near the exit of the staff room and resident bedroom #1, creating an obstruction. (Photograph was taken.) LPA observed a rolled up rug in front of resident bedroom #1, creating an obstruction. (Photograph was taken.) ADM moved the rug during visit. LPA also observed the sideyard, between staff room & the living room had a narrow walk way. (Photograph was taken.) LPA advised ADM to ensure the facility is free of clutter and to ensure all passageways inside & out are free from obstruction. ADM agreed and understood. Page 1 Out of 2. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 116 degrees F in both resident bathrooms. Fire extinguisher was serviced in 7/12/2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on November 1, 2024. LPA reviewed facility records for 3 staff and 1 residents. LPA requested to review R1's admission agreement. LPA observed the facility was using the LIC604A form for the admission agreement. LPA observed R1's admission agreement has pages 1-5, but does not have pages 6-8. (Page 8 of the LIC604A has a section for signatures for the resident/ Residents responsible party/ licensee/facility representative.) ADM stated the admission agreement was signed, but she could not find it. LPA reviewed 1 resident medications and centrally stored medication records. LPA provided ADM with CDSS Flyer, "Important updates to Dementia Care and Miscellaneous Changes, effective January 1, 2025." Deficiencies cited during today's visit. This report was reviewed with Administrator Wennie R. Concepcion and a copy of the signed report was provided. Appeal Rights were provided. Page 2 Out of 2. END OF REPORT.