Routine inspection·June 9, 2023

Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Lead Staff, Quirino Sombito. Administrator Imee Villegas was contacted and arrived later in the visit. The facility is a single story home licensed for six non-ambulatory residents and a hospice waiver capacity of three. The facility currently provides care for five residents, one of which is on hospice and some of which with a diagnosis of dementia. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator and staff; 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 6/8/2023 at the time of visit. Smoke detectors and carbon monoxide detectors were all tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored and secured in locked cabinets in the facility kitchen, bathroom sinks and in the garage/laundry areas. There was a supply of cleaners, hygiene products and paper products available for resident use. All resident’s bedrooms have lighting, appropriate furnishings and an ample supply of clean linens. Water was measured at faucets accessible to residents and measured between 115.7 and 117.1. degrees F which is within regulation. Residents were observed interacting with staff in the common area, or watching television in their bedrooms. Residents appear to have positive relations with staff but participate in activities individually. LPA tested resident call pendants for staff assistance which signal to the kitchen for staff to respond. There are two emergency exits located in the backyard both of which were found to be unobstructed. All auditory alarms at resident bedroom and facility exits were found to be functioning. LPA observed a separate refrigerator located in the kitchen area that stores prescribed medication. Licensee has previously purchased an attachable lock but has not yet installed. Licensee agrees to install the lock to secure medications within the day. Photo corrections to be sent to CCLD for corrections. Technical Violation issued. Continued onto LIC809-C During the inspection LPA observed a camera located along the corner of resident (R1's) bedroom. LPA found that the camera was requested by R1's family and purchased by the facility Administrator. The camera is for the purpose of monitoring private caregiver assigned by the family who accompanies R1 during overnight hours. LPA and Administrator discussed the need for an exception in order to continue using the camera in R1's bedroom as it is a private space and potential violation of resident rights. Administrator agrees to review with R1's family and submit an exception letter request to CCLD along with appropriate documentation. Department to review and return at a later date. LPA was informed that the facility is undergoing a full file organizing and has relocated the current staff and resident files at their main office. LPA will be returning to the facility for an annual continuation to complete review of all facility files, training records, medication review and for updates on the exception request regarding camera installed in resident R1's bedroom. Administrator, Imee Villegas's Administrator Certification 6030808740 is valid through 6/9/2024. LPA requested the following documents be sent to CCL by COB 7/9/2022: 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 No deficiencies cited during today's visit. No deficiencies cited during today's visit.