Routine inspection·September 12, 2023

9/12/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Lead Staff, Rayna Yu. Administrator, Maria Buna was contacted and arrived later in the visit. The facility is licensed for 6 non-ambulatory and 1 bedridden resident and a hospice waiver for 2. The facility currently provides care for 4 residents, one of which is receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Lead Staff, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility exits were equipped with auditory alarms for residents with dementia all of which were found to be functioning. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 11/22/2021 and is in need of inspection. 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 food stored properly. Facility also follows appropriate dietary protocol for resident in care. Toxins, sharps and other items that could pose threat if readily available to residents were kept secured under restroom sinks and storage cabinet in the backyard. Residents were observed engaging in discussion with staff and one another, resting or visited by family. Residents appear to have a positive relationship with staff based on LPA observations. There was a supply of hygiene products, continence products, paper products and clean linens available for residents. All resident bedrooms have lighting & appropriate furnishings. Medications located in a designated cabinet in the kitchen and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Upon count LPA found all administered medication to be in order. LPA also conducted a file review for all residents and found all resident records including physician's report and needs & service plans updated. Lastly, facility conducts and records emergency disaster drill on a quarterly basis. Continued onto LIC809-C LPA toured the backyard and found two emergency exits located on the sides of the home to be unobstructed. LPA observed separate shed located in the backyard that the facility staff utilize for overnight sleeping during shift changes. Upon LPA interview, staff confirmed using the quarters for overnight sleeping into the following morning shifts. The facility does not have an updated fire clearance or facility sketch approving the use of the shed for living and staff sleeping quarters. Suisun City Fire Marshall, Jose Colin was contacted and arrived at the facility to make additional observations of the staff living quarters. LPA and Fire Marshall both concluded observations and determined that the facility will require a fire clearance and facility sketch. Staff quarters are to be immediately vacated. Fire Marshall will be notifying code enforcement. **Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation. 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. LPA requested the following documents be sent to CCL by COB 10/12/2023: 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.