Routine inspection·September 21, 2024

Licensing Program Analyst (LPA) Maria (Mita) Partoza a conducted an unannounced required 1 year inspection visit and met with administrator Shu Jen Collado and stated the purpose of the visit. The facility is licensed to serve adults 60 and over of which 3 may be non-ambulatory. LPA observed 5 out of 6 residents are present at the facility that have neurocognitive impairment, 3 staff (S1 to S3) were present and attending to residents. At 2:00 p.m. LPA toured the facility inside and outside with S1 including but not limited to the kitchen, bathroom, dining room, living room, 4 residents rooms, office/bedroom and laundry area backyard and exterior walkways. The temperature inside the home was at 73 degrees Fahrenheit. The kitchen was observed to be sanitary and organized, knives and sharps were locked and not accessible to residents. LPA observed 2 days of perishable food and 7 days of non-perishable food. Under the sink cabinet is used to store pots and pans. The kitchen water temperature measured at 114.6 degrees Fahrenheit. The facility is maintained, sanitary. The bathrooms are equipped with grab bars, non-skid mats. The water temperature in the bathroom measured between 114.6 degree Fahrenheit. Resident's room (R1 to R6) have sufficient storage, organized and sanitary. LPA observed that medications are kept locked and inaccessible to residents. The first aid kit is complete and is accessible to staff. The backyard, walkways, ramps and patio are free from debris and obstruction. The facility screen windows were observed to be in good repair. The washer and dryer are in god working condition. Laundry soap and cleaning supplies are locked and not accessible to residents in care. page 1 of 2 The facility is equipped with a fire, smoke and carbon monoxide alert system that is in good working condition, night lights on the hallway are in good working condition. The hallway are free from obstruction. LPA reviewed 3 out of 6 resident records such as but not limited to the centrally stored medication and destruction record (CSMDR), admission agreement, needs and services plan, health screening and observed records the following; 2 out 3 (R1 to R3) were missing consent form, appraisal needs and services plan. R1 to R3 are missing information on the personal rights document. R1-R3 are missing information on the emergency ID. R3 is missing the second page of the physicians medical report. LPA reviewed 4 out of 8 staff records including but not limited to required training, first aid/CPR training, health screening and background clearance. 4 out 8 (S1 to S5) staff have criminal record clearance/fingerprints that are completed and updated. 1 out of 8 staff (S5) started at the facility 9/1/2024 and has criminal background/fingerprint clearance. Licensee stated, he/she is in the process of transferring the criminal record clearance of S5. LPA was able to verify eligibility of S5 through Guardian. S5 was observed providing care and supervision to residents in care. Deficiency is cited during today's visit base on California Code of Regulation (CCR) Title 22 87355(c)(1) and 87506(a). An exit interview was conducted with administrator Shu-Jen Collado. A copy of the report and appeals rights were provided. page 2 of 2 end of report