Routine inspection·June 26, 2024

At approximately 11:30 AM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by Delia Ulbata, Licensee/Administrator. The facility is a single story home licensed for ten (10) non-ambulatory residents and a hospice waiver capacity of two (2). The facility currently provides care for 8 residents and there is one resident under hospice care at this time. At approximately 11:45 AM, LPA and Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected ,There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked cabinet in the facility laundry room and kitchen. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen cabinet. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Water temperature measured within regulation between 109 and 113 degrees F at three of three faucets accessible to residents. One out of one fire extinguisher was inspected and charged. Thirteen out of thirteen Smoke Detectors and two out of two Carbon monoxide detector were present inspected. There was enough lighting in all common areas, resident rooms, and hallways. Medications located in designated cabinet were found to be secured. LPA conducted a spot check of medications and found all administering and records to be in order. Continued on LIC809-Ca Continued from LIC809 At approximately 12:25PM, LPA reviewed Eight out of Eight resident records which were all found to be well organized but missing the required documentation(Updated LIC602, Signed LIC613, LIC601). At approximately 1:00 PM, LPA reviewed two out of two staff records which did not include Administrator's staff file but not on site. LPA advised Administrator all required documentation must be kept at the facility and accessible to CCLD/LPA. LPA advised citation was given on 07/23/23 for missing training files Civil Penalties assessed for repeat violation. Medication records are thorough and contained physician's orders for each resident. Administrator Administrator Certification is current and expires on 06/23/2025. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC 500 Personnel Summary LIC 9020 Register of Facility Client’s/Resident's LIC610- Disaster Plan (updated with non-local evacuation site) Staff Training Records including First Aid for all staff Updated LIC602 for all residents Signed LIC613 for all residents LIC601 for all residents Evidence of Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in additional civil penalty assessment. This report was reviewed with Delia Ulbata and Appeal rights were given.