Routine inspection·October 19, 2023

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Lead Staff, Imuentinyan Ibinigie. LPA Rai observed 1 staff and 1 resident at the facility and 2 residents were attending day program. Licensee/ Administrator was notified of the visit but was not available for today's inspection. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. The facility bathroom had available soap, paper towels, and trash cans with lids. The shower had grab bars and non-skid mats. The water temperature in the bathroom faucet was recorded at 112.3F. The water temperature in the kitchen sink was 110.7F. Fire extinguisher was observed and inspected on October 20, 2022. S1 stated the company overseeing the fire system will stop by tomorrow to do the annual inspection for the fire extinguisher. Facility smoke detectors and carbon monoxide detectors were in working condition. 3 out of 3 resident bedrooms had available bedding, drawers, and functioning lights. LPA Rai reviewed facility records for 3 residents. The facility did not maintain staff records and was not available for LPA Rai to review. S1 states the facility does not have a central administrative location where the staff records would be kept outside of the facility. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. LPA Rai reviewed R2's medications and central stored medication records. LPA observed the 3 out of 3 resident's file contained a blank LIC 622 Centrally Stored Medication and Destruction Log which did not contain the necessary information. S1 stated he/she has not used the LIC 622 form to record resident's medications. During review of R2's medications, S1 kept 2 medications in the fridge which was unlocked and accessible to persons other than employees responsible for the supervision of the medication. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. One Technical Violation Note was provided during today's visit. This report was reviewed with Lead Staff, Imuentinyan Ibinigie and a copy of the report was provided. Appeal Rights were provided.