Routine inspection·January 22, 2025

On January 22, 2025, at 08:50 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 caregiver, Elsa Lopez, and disclosed the purpose of the inspection. The caregiver informed the LPA that the facility had (6) residents in care and (3) staff members present at the time. LPA observed (2) staff members in the kitchen preparing breakfast and (1) staff member assisting residents with the breakfast on the dining table. At 9:24 AM, the LPA initiated a walk-through of the facility, accompanied by the caregiver. 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. The LPA observed (5) residents eating breakfast at the dining table. LPA inspected the living room and observed it clean, with all furniture in good repair. There were reclining chairs and a television in the living room. LPA inspected the fire extinguisher mounted on the wall in the living room and found it fully charged, with the last service tag dated 04/09/2024. The caregiver tested the smoke and carbon monoxide detector located in the hallway in the LPA's presence, and it was found to be functional. There were (6) bedrooms and (2½) bathrooms designated for residents' use. All resident rooms were single occupancy. LPA inspected all (6) resident rooms and found them clean, well-lit, and equipped with the required furniture. LPA observed scissors on a table in room #1 and another scissors on top of chest in room #3, accessible to residents. LPA inspected (2) 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 mats. The hot water temperature at the sink faucet measured 108.5°F in bathroom #1 and 109.2°F in bathroom #2. Continued on 809-C 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, and a locked cabinet under the sink with detergents and cleaning supplies. 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 storage closet in the hallway and observed it contained clean linens, blankets, and towels for residents’ use. LPA inspected the garage and found it clean. A washer, a dryer, a freezer containing additional food supplies, and a closet containing detergents 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. No bodies of water were noted. The LPA inspected (2) storage sheds and observed wheelchairs, furniture items, bedframes, mattresses, outdoor furniture, outdoor heaters, and PPE products stored in the sheds. Auditory alarms was observed to be working on all the exit doors. LPA reviewed (6) staff personnel records and (5) resident records. The LPA observed that 5 of 5 residents had an Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, and CSDMR. 1 of 5 residents (R4) was missing a completed safeguards for property/valuables form. 1 of 5 residents (R2) was missing personal rights forms. 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. Medications were organized in separate bins for each resident. 6 of 6 resident medication prescription labels were altered with the handwritten notes using a black marker pen. Centrally Stored Medication Records (CSMR) 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 11/20/2024. Continued on 809-C The following updated forms are requested to be submitted to CCLD by 01/29/2025: LIC 500: Personnel Report LIC 308: Designation of Facility Responsibility LIC 999: Facility Sketch (Floor Plan) Certificate of Liability Insurance Current Property Lease Agreement Administrator Certificate(s) A deficiency is 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 caregiver. A copy of this report and appeal rights were discussed and left with the caregiver, Elsa Lopez, whose signature on this form confirms receipt of these documents.