Routine inspection·June 4, 2024

On 6/4/2024, Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted a required annual inspection and was greeted by 2 staff. License/Administrator (LIC/ADM) Yiwen (Nicole) Shih was not present and designated Administrator (DADM) Rita Garcia was not in the facility. A staff called the DADM and DADM arrived within 5 minutes. LPA stated the purpose of the visit to DADM. The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over, capacity of 6, 5 non-ambulatory and 1 ambulatory. The facility has a waiver for 2 hospice care. The facility's has 6 residents (R1 to R6) that have neurocognitive impairment. 2 staff were present at the time of the visit. 6 residents were present at the facility. 1 out of 6 were in the dining area. 1 out of 6 residents are in the backyard, 3 out of 6 were in the bedroom 2 out of 6 are non-ambulatory and 4 of 6 are ambulatory. LPA and ADM toured the facility inside and outside, including but not limited to the following: Kitchen, dining, laundry, garage, 5 resident room, 1 staff room, 2 bathrooms, backyard and the exterior walkways. The facility has access to two facilities under the same ownership. LPA checked Guardian and found that on 12/18/2023 a notice from the California Department of Social Services(CDSS), Care Provider Management Bureau (CPMB) was sent to licensee/administrator (LIC/ADM) informing the LIC/ADM that a criminal record exemption is required for S1. LIC/ADM did not submit the requirement as requested by CPMB within the given time frame. S1 stated that he/she started working at the facility 12/5/2023 and was aware of the exemption letter and requirement. S1 stated he/she passed on the letter to LIC/ADM when S1 received the letter in December of 2023. LPA discussed the importance of responding to CPMB to LIC/ADM, DADM and to S1. page 1 of 2 At the time of record review for the facility, LIC 308 Designation of Facility Responsibility was not completed. LPA requested the following documents: LIC 500, LIC 308, Lease Agreement, Liability Insurance, resident roster and staff background clearance record. Deficiencies is being cited during today's visit based on California Code of Regulation, Title 22, please see LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days) for staff (S1) working at the facility without criminal record clearance or exemption. See LIC 421BG. Due to time constraint the annual inspection will be continued at a later date. An exit interview was conducted with Designated Administrator Rita Garcia. A copy of the report and appeals rights were provided. page 2 of 2