Routine inspection·June 1, 2023

Licensing Program Analyst Bertozzi arrived unannounced to conduct an Annual Required Inspection and met with Licensee/Administrator, Luninging (Bot) Alicdan. There were three care givers on duty to provide care and supervision for ten residents. Facility currently has three residents on hospice which is allowable per the facility's Hospice Waiver. Facility also has a waiver to have a secure perimeter. LPA initiated a tour of the facility around 9:40 am and made the following observations: Facility was a comfortable temperature with thermostat reading at 71 degrees F. Passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sink accessible to residents in care measured at 109 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinet containing medications was locked. Kitchen cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods. Fire extinguisher was last inspected June 2022. Carbon Monoxide detectors were tested and operational. Facility has a fire alarm system that is maintained by a vendor. Facility was recently inspected by the local fire department and no issues were noted regarding fire alarms. Three staff files and ten resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Luninging Alicdan 6010428740 expires 10/18/2023. Medications and medication records were reviewed. Training records were reviewed. Required postings were observed. LPA confirmed that facility has valid Liability Insurance Continued on LIC809C Continued from LIC809 Licensee provided LPA a copy of their liability insurance and LIC 308 (Designation of Responsibility) forms. Licensee/Administrator to submit updates of the following documents by 7/01/2023: LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (If changes) Infection Control Plan (If changes) Deficiencies 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.