Routine inspection·October 20, 2022

Licensing Program Analyst (LPA) Alviso, conduct a Required- 1 Year inspection and met with Lead staff Joyce; LPA observed another caregiver working, Grazelle.. The inspection is focused on the Infection Control procedures and practices of the facility. The LPA was screened as required by staff, including LPA's temperature, all information was logged as required. Administrator has submitted the Infection Control Plan as required. There is an approved hospice waiver for two (2) residents. There is an approved plan of dementia care. Fire clearance is approved for six (6) non-ambulatory. Per Administrator, fire extinguishers, two(2) of them, were purchased within the last few months from Costco; The Administrator will attach copy of receipt to extinguishers and ensure they are both serviced and tagged as required.-annually. There were three(3) residents in care at the facility during the inspection. LPA observed the facility to be clean and orderly. The facility was at a comfortable temperature for the residents in care. There was a sufficient supply of food for residents in care. All exits were unobstructed. There was a sufficient supply of hygiene products, paper products, and cleaners. Sufficient supply of PPE. Medications are locked and inaccessible to residents in care. Toxins and cleaners are locked and inaccessible to residents in care. LPA observed the following deficiencies: LPA observed that the garage has been renovated/conversion to have staff room and 2nd bed set-up and used by staff. Continued on LIC809C The garage conversion was completed without permits and Licensee had not notified the licensing agency of any changes to the facility grounds. This can jeopardize the facility's fire clearance. LPA contacted the Rohnert Park Fire Inspector who arrived to inspect the garage conversion. The Fire Inspector Jim Thompson left an inspection record to the Licensee for follow-up on the conversion that was not permitted. Deficiency will be cited, Fire Safety 87203-see LIC809D. LPA observed staff (S1) to greet the LPA in the facility front entryway without a mask on. This will be cited, Personal Rights 87468.1(a)(2) - see LIC809D. LPA observed staff change a resident, provide incontinent care services, in the open sitting area of the facility, this is by the front door entry. The resident was not given personal privacy when being provided personal care needs. This will be cited, Additional Personal Rights of Residents in Privately Operated Facilities 87468.2(a)(1)-see LIC809D. 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. Licensee/Administrator to submit the following documents by 10/31/22: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 9020 Register of Residents LIC 610 E Emergency Disaster Plan for Residential Care Facilities for the Elderly Copy of Liability Insurance