Routine inspection·December 22, 2022

Licensing Program Analyst(LPA) Alviso arrived unannounced to conduct a Required 1 Year inspection and met with Licensee/Administrator Eden Relota. There were two other caregivers, Robert White and Henedina(Heidi) Jumalon , on duty during the inspection. The inspection is focused on the Infection Control procedures and practices of this facility. Administrator submitted to the Department, as required, the facility's Infection Control Plan. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Fire clearance is approved for four (4) non-ambulatory, of which one(1) may be bedridden.There were four (4) residents in care at the facility. Staff screened LPA for covid symptoms, including temperature being taken; Staff logged the screening information. LPA reviewed resident and staff files. Two residents are receiving hospice services. All staff have criminal record clearance as required. S 4 lacked current first aid certification, deficiency will be cited, 87411(c)(1) Personnel Requirements -General, see LIC809D. Facility was found to be clean, and at a comfortable temperature with all exits free from obstruction. Carbon monoxide detector was working when checked during the inspection. All smoke alarms were working when checked during the inspection. Toxins are stored in locked cabinets. Medications were locked in a cabinet making them inaccessible to residents in care. All bathroom(s) had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Sufficient food supply. Continued on LIC809C... . LPA observed the fire extinguisher was not serviced and tagged as required-expired 11/18/2022,, and LPA observed the garage to have an area set up as a staff sleeping/living area, with staff's personal belongings in this area, deficiencies were cited, Fire Safety 87203, see LIC809D. LPA discussed Fire Safety regulations with the Licensee, who stated their understanding to the LPA. The Licensee stated that she will submit plan of correction on all deficiencies cited. The following deficiency(s) was/were cited from 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 provided to the Licensee/Administrator. LPA requested Licensee to update the following documents by 1/9/2023. LIC 308 Designated LIC 500 Personnel Summary-all staff names/titles-days/hours working LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s. Copy of Administrator Certificate Copy of Certificate of Liability Insurance