Routine inspection·July 10, 2023

Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and was granted access into the facility. LPA met with House Manager Imelda Garcia. LPA toured the facility which was found to be at a comfortable temperature. LPA observed a supply of linens (bedding, towels, etc.), and cleaning solutions (observed locked & inaccessible). Resident bedrooms were furnished per regulation. Facility food supply was within regulation and accessible to residents. Medication was centrally stored. Fire Drill was conducted on 07/08/2023. There are 8 smoke detectors & 1 carbon monoxide detector, which were tested & observed operational. LPA reviewed staff and resident records. Staff have current training certifications in First Aid & Cardiopulmonary Resuscitation (CPR) in file. The following deficiencies were observed during today's inspection: Building Permit Violation: During inspection, LPA observed 1 of 1 constructed staff bedroom located in the garage with a 1 bed and 1 bunk-bed, dresser, and personal belongings (photos taken). Staff (S1) unlocked the door from the inside of the staff bedroom in the garage and stated they were currently off work and getting dressed. The facility does not have a building permit for the staff bedroom in the garage and staff are occupying the bedroom at this time. Facility did not submit a building permit to CDSS CCL as required. Administrator stated the staff only use the bedroom to store their belongings on their shift. LPA previously discussed with Administrator on 04/19/2023, 01/25/2023, 06/28/2022, 06/02/2022, 05/23/2022 that the bedroom is required to be inspected and approved by the Fairfield Fire Department, and Licensee must obtain a building permit to ensure it is safe for staff to occupy. Administrator understood. **LPA informed licensee that individuals (specifically staff) are not allowed to sleep or occupy the shed in backyard, staff bedroom in the garage (which does not have a permit), or common areas (living room couch, etc.). Facility will operate with an awake staff as there are no staff rooms approved. Fire Safety Violation: During inspection, LPA observed 2 of 2 fire extinguishers were charged but last serviced over 1 year ago on 03/15/2023 (photos taken). LPA discussed with Administrator that fire extinguishers shall be serviced annually per regulation. 3 of 6 resident bedroom direct exits were blocked by (R5) chair, (R3) night stand with TV and TV tray, and (R2) by residents bed. photos taken Report continued on LIC809-C Staff Training & Health Screening Violation: During record review, it was revealed staff have not completed or have documented initial or annual training as required. Additionally LPA observed 5 of 5 staff records reviewed did not have a health screening completed with TB test as required. (photos taken) Medical Assessments, Appraisals, & TB Test Violation: File review revealed resident (R1 who is diagnosed with dementia) has a Medical Assessment (LIC602A) that is out of date, last completed on 03/21/2022 and their Appraisal Needs and Service Plan (LIC625) is also out of date (photos taken). Resident R5 is missing a completed LIC 625. Resident R3 requires a Tuberculosis (TB) test done. Additionally have Resident (R4) re-assessed for their ambulatory status due to being Bedridden on their LIC 602 but LPA observed resident walking during inspection. House manager stated R4 is non-ambulatory. Maintenance & Operation: LPA tested the water temperature during inspection. LPA observed kitchen sink faucet water to be 132 degrees F but had a yellow warning sign "Caution Hot Water" per regulation. LPA tested water temperature in the 2 of 2 resident's bathrooms (which are used by residents) which were 132.4 degrees F. Assistant manager lowered water temperature during inspection on water heater and notified House Manager Enrique. LPA requested the following updated forms to be submitted to Community Care Licensing by 08/10/2023: · LIC 308 Designation of Facility Responsibility (1 person per form) · LIC 500 Personnel Report · LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents) · Copy of Liability Insurance · LIC 9020 Facility Register of Client/Residents · LIC 610E Emergency Disaster Plan · Copy of current Administrator's Certificate LPA requested an updated facility indoor and outdoor sketch showing the newly built shed in the backyard. Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal Rights Provided. *** An immediate civil penalty in the amount of $500 was assessed for blocking direct fire exit in resident R2 and R3's room Exit interview conducted with Assistant Manager, whose signature on this document confirms receipt. This report was emailed to Administrator