Routine inspection·October 10, 2023

Licensing Program Analyst (LPA) Carol Fowler conducted a Required- 1 Year visit, on 10/10/2023 at approximately 9:00am, and met with Macristina Calata, Caregiver. Administrator arrived at approximately 10:19am Administrator Certificate, #6052482740, has expired 06/09/2023 Administrator has applied for renewal. . LPA observed one caregiver working at the time of arrival. There are currently four (4) residents in care. There is an approved hospice waiver for three (3) residents. Facility has a required infection control plan. Facility has an emergency disaster plan as required. The facility last conducted a fire and earthquake emergency drill on 11/02/2022. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden approval. All exits were free and clear of obstruction. Fire extinguisher, was serviced and tagged as required, expires 07/17/2023. LPA observed seven (7) smoke alarms, including 1 carbon monoxide detector, all working properly during the inspection. Facility was found to be clean, orderly, and at a comfortable temperature. Hot water was checked at 109.4 F, which is within regulation. Medications were stored and locked making them inaccessible to residents in care. Continue on LIC809C Continue from LIC09 Deficiencies observed during tour: There are currently four (4) residents in care. LPA reviewed three (3) of four (4) resident files; All resident files were found to be incomplete and missing from the facility. LPA could not reviewed staff files because they were not located at the facility. Facility last fire drill was conducted on 11/02/2022. Chemicals under kitchen sink were accessible to residents in care. Pre-poured medications 7days +. LPA is requesting the following documents be updated and submitted by 10/18/23: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required) Infection Control Plan Control of property Copy of Current Liability Insurance Copy of current Administrator Certificate Deficiencies 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 with the Administrator. Appeal rights were provided.