Routine inspection·November 8, 2021

On 11/8/2021 at 10:40am Licensing Program Analyst (LPA) Ashley Boothe arrived unannounced to conduct a Required 1-year Annual inspection. LPA contacted Licensee prior to today's inspection who confirmed no staff or residents have tested positive or shown symptoms within the past 10 days. LPA met with Designated Staff (S1) and was allowed entry into the facility that is licensed to serve a total capacity of 6, today's census is 3. One of one staff observed on site with criminal record clearance in Licensing Information System. LPA observed Administrator Certificate expires on 7/27/2023. Two of two persons on site residing in the facility with criminal record clearance. LPA interacted with a random number of residents during this visit and observed residents. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed kitchen, laundry room, garage, restrooms, bedrooms, and common living areas to be clean and in good repair. LPA observed items not secured accessible to residents including personal care products and cleaning chemicals in residents restroom, knives in kitchen unlocked. S1 locked kitchen cabinet and began to secure toxins during today's visit. The temperature inside the facility was measured at 72*F which is within the required range of 68*F and 85*F, or in areas of extreme heat the maximum shall be 30*F less than the outside temperature. The hot water was measured at 110*F within regulatory range of is not less than 105*F and not more than 120*F. LPA observed the centrally stored medications to be locked inaccessible to residents. LPA observed Centrally Stored Medications Log and all medications stored separately. One of one medications counted matched Centrally Stored. The first aid kit was missing scissors but otherwise in compliance containing at least the following: a current edition of an approved first aid manual, sterile first aid dressings, bandages or roller bandages, adhesive tape, tweezers, thermometers, and Antiseptic solution. S1 stated they would add scissors to the first aid kit. Continued on 809 C. Continued from 809. LPA observed fire extinguisher last inspected on 1/8/2021, smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. LPA observed COVID precautions signs posted, restrooms stocked with hand soap, hand washing signs posted but no touchless covered trash cans or paper towels. LPA observed 30 day supply of PPE stored is stored. The facility has an approved Mitigation Plan. Upon a file review the following items were discussed to be submitted to LPA by 11/20/2021: Designation of Administrative Responsibility LIC308 Qualifications of Administrator Personnel Report LIC500 Emergency Disaster Plan LIC610D Per California Code of Regulations (CCRs) - Title 22, Division 8, the following deficiencies are being cited on the attached 9099D during this visit. A copy of their rights (LIC9058) provided and a signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report provided.