Routine inspection·June 11, 2024

At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Licensee/Administrator, Victor Dada. Facility serves older adults and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 2 individuals. Facility has approval to have a locked perimeter. Upon arrival, LPA was informed that there were 2 Residents in care and 3 staff members on-site. At approximately 9:55AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:00AM, LPA conducted a walk-though of the facility with Licensee. LPA observed the following: Facility is a one story building with six bedrooms, six bathrooms, and common spaces. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. LPA observed that one facility's fire extinguisher shows that it was last inspected April 2023, while the other fire extinguisher was shown to be last inspected April 2025 (see LIC9102, Regulation 87202(a)). Per interview with Licensee, they have not done an emergency/disaster drill recently (see LIC809D, Health and Safety Code, 1569.695(c)). Licensee understands that emergency/disaster drills are to be conducted at least quarterly per Health and Safety Code. During walkthrough, LPA observed the following toxins to be accessible: Snuggle scented dissolvable beads, Tide Detergent Pods, floor cleaner, and flea/tick repellent (see LIC809D, Regulation 87705(f)(2)). Licensee immediately collected all toxins and ensured that they were locked. Smoke and carbon monoxide detectors were tested and operational. At approximately 11:00AM, LPA reviewed staff files, resident files, and resident medications. Continued on LIC809C Continued from LIC809 Review of staff files showed that 1 of 3 staff members were missing their Health Screening (LIC503) report. 2 of 3 staff members did not have annual 2024 training completed (see LIC9102, Regulation 87411(f), and LIC809D, Health and Safety Code, 1569.625(b)(2)). Staff files had current First Aid and CPR certification, and proof of negative TB tests. Review of Resident Files showed that 2 of 2 files were missing their Pre-Appraisal Assessments (LIC603) (see LIC809D, Regulation 87506(b)(15)). Licensee understands that Pre-Appraisal assessments should be conducted prior to residents moving into the facility. Licensee also understands that assessments and appraisals should be conducted annually for residents with a dementia diagnosis. LPA observed that 2 of 2 resident files did not have a Needs and Services Plan (see LIC9102, Regulation 87467(a)). Review also showed that 1 of 2 resident files were missing hospice documentation (see LIC9102, Regulation 87633(b)). Per interview with Licensee, resident just moved in, and they are still waiting for hospice documentation to arrive. Administrator's Certificate for Victor Dada (6000794740) expired 03/31/2024. Review of the Department website showed that renewal payment has been received and is pending as of 01/11/2024. LPA requested the following documentation to update the facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610D) Updated Personnel Report (LIC 500) Register of Clients/Residents (LIC 9020) Updated Lease Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 07/11/2024. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.