Routine inspection·May 17, 2023

On 05/17/2023 at 10:00am, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct an annual visit. LPA was greeted by staff member (SM), Marvin Chy, and explained the purpose of the visit. LPA asked SM Chy to go ahead and inform the Facility Designated Administrator (FDA) that licensing was present at the facility. Shortly after, LPA met Facility Designated Representative (FDR), Maria Andrade. It was learned at this time that FDA West was not available. There were two other staff members present during this visit, Taylor Andrade and Alethia Alvarez. This facility is licensed to serve up to 6 elderly residents. This facility does not currently have a dementia plan on file and does not have a hospice waiver. Current census was 6. A brief interview was conducted with FDR Andrade. LPA reviewed 6 resident files. 6 out of 6 resident files were current and up to date. LPA reviewed 6 staff files. 4 out of 6 staff files were complete. The Facility Designated Administrator has an active and current administrator certificate #6059262740 and expires on 08/10/2023. A tour was initiated with FDR Andrade. Fire extinguisher was serviced by Jorgenson Co and is valid until 06/01/2023. Smoke alarms and carbon monoxide were in good repair. A tour of the kitchen was conducted. LPA observed a sufficient amount of 7 day non-perishable food supply as well as 2 day perishable food supply in the main kitchen. Knives were observed to be locked and made inaccessible to the residents. Additional perishable food supply was identified in the garage. LPA observed a locked centralized stored medication cabinet. Along with FDR Andrade, LPA reviewed and compared medication with medication dispensing logs. LPA observed a locked cleaning supply cabinet. First aid kit was present and contained all the required components. Living room area, dining room, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be in good repair and sufficient to meet resident needs at this time. A tour of 3 resident bedrooms were conducted. Resident furniture was observed to be sufficient to meet their needs at this time. A tour of the resident bathrooms were conducted. Hot water temperature was within the required range of 105-120 degrees. Grab bars were present. Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. A tour of the exterior physical plant was conducted. Perimeter fence, side gates, and exits was inspected. The following forms and documents were requested to be updated and submitted into CCL: -LIC 308 -LIC 400 -LIC 500 -LIC 610 -Liability insurance The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Code. Exit Interview was conducted, a copy of this report and appeals rights were provided to the Facility at the end of this visit.