Routine inspection·September 7, 2023

On 9/7/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Licensee, Al Balbuena. The facility is single story building licensed for 3 non-ambulatory residents, one bed-ridden resident and a hospice waiver of two. The facility currently provides care for three residents, one of which was present and two of which were on community outings or appointments at the time of visit. There are currently no residents receiving hospice services but some of which have a diagnosis of dementia. LPA continued with a tour of the facility with Lead Staff and Licensee, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 11/8/2022. Both smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with additional food supplies in the garage. Facility also follows appropriate dietary protocol for resident in care. Toxins were located in the garage and laundry room both of which were found to be secured. LPA toured the facility backyard and found all bedroom screens in good repair and found one emergency exits located in the side yard to be clear and unobstructed. Resident was observed interacting with staff in the common area, enjoying lunch and resting in their bedroom while LPA conducted inspection. Relations between staff and resident are positive and resident appears to be comfortable. There was a supply of hygiene products and paper products available for residents. All resident bedrooms have lighting & appropriate furnishings. Medications located in dinning area were found to be secured. LPA conducted spot medication count and found several medications for 3 out of 3 residents not properly input or completed on the Centrally Stored Medication Records. Continued onto LIC809-C LPA conducted a file review for all 3 out of 3 residents and found all Physician's Reports updated. LPA found that resident (R1) requires an updated Needs & Service Plan to account for recent changes of medical conditions. Technical Violation issued. In addition, LPA Tobola requested for Licensee to ensure signatures for all resident personal rights forms. Technical Assistance provided. LPA also conducted a sample staff file review and found staff (S1) in need of an updated 1st Aid & CPR certification. Technical Violation issued. Licensee , Al Balbuena's Administrator Certification 6029935740 is valid until 3/11/2024. LPA requested the following documents be sent to CCL by COB 10/7/2023: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Liability Insurance Control of Property Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.