Routine inspection·April 29, 2022

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 4/29/22 at 12:30PM to conduct an annual inspection visit. LPA met with the caregiver Carlo Ocampo and explained the purpose of the visit. Carlo Ocampo, Caregiver contacted the Administrator regarding the visit. At this time there are 3 residents receiving hospice services. Administrator certificate expires 12/16/23 for Voica Matias. The Licensing fees are current at this time. Rainilda Clavano a rrived within 15 minutes to assist with todays visit. The facility is licensed for a capacity of 6 residents. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents during this visit. LPA observed 2-day perishables but not a supply of 7-day non-perishables during this visit. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 129.3*F which is not within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, pull alarm system, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Upon a file review the following items were discussed to be submitted with any changes annually: A copy of the signed Hospice Waiver for 2, Control of Property, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500), Theft and Loss Policy and Procedures, Transportation Procedures, Administrator Certificate-Updated, Liability Insurance, LIC 610E(3/19) Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Licensee was provided a copy of their rights (LIC9058 12/15) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided. See 809D for continuation...