Routine inspection (multi-day)·February 19, 2025

Licensing Program Analysts (LPAs) Alviso and Contreras arrived unannounced to conduct a Required -1 Year inspection, on 2/19/25 at approximately 12:20pm, and met with caregivers Ann and Fredah. Staff contacted Administrator Monicah Gacegu and notified them the LPAs were at the facility. The Administrator arrived to meet with the LPAs. Fire clearance is approved for eight (8) non-ambulatory only. There were seven (7) residents in care at the facility during the inspection. ` Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. The facility has a required infection control plan. The facility has a required emergency and disaster plan. LPAs reviewed seven (7) resident files, including storage of medications and medication records. LPAs reviewed three (3) staff files, including training. All staff have required criminal record clearance. LPAs toured the facility with the caregiver Fredah; LPAs toured the facility with the Administrator when they arrived. LPAs observed cleaners/disinfectants locked and inaccessible to residents in care. All medications were locked and inaccessible to residents in care. All exits were free and clear of obstructions. There was a sufficient supply of perishable and non-perishable food. There was a sufficient supply of hygiene products, linens, paper products, and personal protective equipment (PPE) for use as needed. Carbon monoxide detector was working properly during the inspection. All resident rooms and common areas had required smoke alarms. Fire extinguishers was serviced and tagged as required. There was sufficient lighting in the resident rooms, bathrooms, and all common areas. LPA is requesting the following documents be updated and submitted by 3/19/25: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan- review and if no changes, submit a copy of last page w/signature & Date. If changes, submit a copy of the plan. Continued on LIC809C... Infection Control Plan-review and if no changes, submit a statement w/signature & Date. If changes, submit a copy of the plan. Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond if handling cash.. Copy of Current Liability Insurance Copy of current Administrator Certificate The following deficiencies were observed by the LPAs: LPAs checked the hallway resident bathroom's hot water, and it was checked at 169.9 degrees Fahrenheit; This is not within regulation of no lower than 105. degrees or no higher than 120. degrees Fahrenheit. This deficiency will be cited, Maintenance and Operation Section 87303(e)(2) - Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). LPAs observed an area where it is filled with various size rocks, and it was flooded making it a small pond/small water feature. Water was no longer draining out of this rock filled area. This has never been observed this way prior to today's inspection. The water is at a level where it may be a risk to the health & safety of residents in care. This will be cited, Personal Accommodations and Services 87307(f)- Th e licensee shall supervise residents as needed and as determined by the resident's appraisal, pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to birdbaths, fountains, or similar smaller decorative water features. This will be cited, Per review of records, Administrator could not provide proof of having completed emergency disaster quarterly drills as required. This deficiency will be cited, Emergency Plans HSC 1569.695(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. 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 Administrator Monicah Gacegu. Appeal rights were provided.