Routine inspection·February 6, 2025

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Administrator Darwin Galicia arrived later. Facility has 4 residents with 1 with dementia diagnosis. Facility has fire clearance for 6 Non Ambulatory and cleared for a Hospice Waiver for 3, although no residents currently are on hospice. At approximately 11 am LPA and staff toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. LPA observed locked kitchen cabinet containing cleaning supplies and sharp knives. All bedrooms were equipped with lighting/lamp, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required slip resistant mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 107.6 to 107.7 degrees F, within the allowable range of 105 to 120 degrees F. Fire extinguishers were observed to be charged 19/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 01/03/2025. At approximately 12 PM, LPA reviewed 4 of 4 resident records and found 4 of 4 residents had current Physician Assessmentss on file although 2 of 4 residents did not have current Pre-Admissions Appraisals on file, (see LIC 809-D) Continue on LIC809-C Continued from 809... At approximately 1:00 PM on 2/5/2025 LPA conducted a review of five out of five staff files and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements are current and LPA was presented with proof of CPR & 1 st Aid certification for staff that files were reviewed. Review of staff records revealed staff #4 & #5 do not have required health screening reports and #4 also does not have TB test results (see LIC809-D). Medication is centrally stored in a locked closet in the hallway. Darwin Galicia Administrator Certificate 6002465740 expires 6/1/2025. All fees are current. LPA and Admin discussed facility's Infection Control Plan and Emergency Disaster plan. The following deficiencies were observed (see LIC 809D) and 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 and appeal of rights provided. Appeal of Rights Given. LPA Hansen has requested the following documents updated and submitted to CCL by 2/21/2025. LIC500- Personnel Report LIC308- Designation of Responsibility (if changes) LIC9020 Register of Facility Residents Emergency Disaster Plan (if changed) Copy of Current Liability Insurance (when available)