Routine inspection·July 3, 2023

Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 7/1/23 at approximately 12:15pm, and met with Licensee/Administrator Estelita Guzman. Administrator Certificate, #6049702740, is current- expires 10/16/24 . LPA observed three caregivers working at the time of arrival. There are currently five (5) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for two (2) residents. Facility has a required infection control plan. Facility has an emergency disaster plan as required. The facility conducted a fire drill and an earthquake emergency drill on xxxxx. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden approval. All exits were free and clear of obstruction. Fire extinguishers, two(2), were serviced and tagged as required, expires 8/11/23. LPA observed ten(10) of ten(10) smoke alarms, including carbon monoxide detector, all working properly during the inspection. All exit doors had auditory alarms, and the alarms were working properly during the inspection. Facility was found to be clean, orderly, and at a comfortable temperature. Hot water was checked at 116.4 F, which is within regulation. Medications were stored and locked making them inaccessible to residents. All toxins/cleaners were stored in locked cabinets, and inaccessible to residents in care. Administrator showed the new refrigerator/freezer that had been delivered this am. LPA requested the Administrator have staff transfer all frozen and refrigerated items, that were out, and stored in a plastic storage container, to help ensure the safety of food items being provided to residents. Continued on LIC809C... There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. LPA observed sufficient supply of food, perishable and non-perishable for residents in care. There are currently five(5) residents in care. LPA reviewed five(5) of five(5) resident files; All resident files were found to be complete. LPA reviewed four(4) of four(4) staff files. LPA reviewed staff training. All four(4) staff have criminal record clearance, and are associated as required. All staff had required annual training. All staff had current First Aid and CPR Certification. LPA is requesting the following documents be updated and submitted by 8/3/23: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required) Infection Control Plan-if any changes, as discussed Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond. Copy of Current Liability Insurance Copy of current Administrator Certificate During the tour of the facility, the LPA observed some changes to the patio/deck area of the home. There is no railing/fencing, and no self latching gate on the patio/deck which is open on one whole side; LPA observed no railing or fencing which leaves an open drop to the cement ramp from the deck, and another smaller area of the deck with a drop to the dirt ground, with two drop down steps to it's right, all these areas are a safety hazard. This deficiency will be cited, - 87705 (h) Care of Persons with Dementia -Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents, see LIC809D. Continued on LIC809C... The LPA observed in review of facility records that the last emergency drills were done 1/27/2020 & 9/14/2020. The emergency disaster drills are to be done quarterly. This deficiency will be cited, H&S Code Emergency Plans15965.65(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill, see LIC809D. Deficiencies cited from the 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 were provided.