Routine inspection·August 29, 2023

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct an Annual Required 1 Year inspection and met with care staff, Mark Sambayan and Mark Padilla. Mylene Copero, co licensee and Administrator arrived few minutes later. This facility is licensed for 6 Non-ambulatory residents with a Hospice Waiver approved for 1 of the residents and no Bedridden approval. LPA initiated a tour of the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 115 degrees F which is within the required range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Closet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility maintains emergency food and water supplies. Fire extinguishers were fully charged and last serviced February 9, 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent disaster drill was conducted 8/10/2023. Staff have required First Aid and CPR certificates that expire in 2024. Certificate for Administrator, Johnny "Juanito" Copero, 6017113740, expires on 6/11/2024. Training records were reviewed. Required postings were observed. Medication records were reviewed. Continued Report see LIC809C Two staff files and six resident files were reviewed. Resident files for R1 and R2 were found to not have a current Physician Report (LIC602), last report in file for R1 was documented on 9/2020 and R1 has Dementia diagnoses. R2's Was documented on 6/2022 and was also over a year old and not within the required 1 year for residents diagnosed with Dementia. Yearly Appraisal were also not current. LPA consulted regarding Reporting Requirements, no use of garage for sleeping, Not using a pad lock to lock gates unless they have been approved for locked perimeter from Community Care Licensing and the Vallejo Fire department. Licensee/Administrator to submit updates of the following documents by 9/28/2023: LIC 500 Personnel Summary- LIC308 Designation of Facility Responsibility LIC 610 Emergency Disaster Plan (If changes) Infection Control Plan (If changes) Copy of Liability Insurance Copy of Administrators Certificate COPY of updated Facility sketch The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided by email.