Routine inspection·July 26, 2023

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:15PM. The LPA met with Licensees Teresita and Larry Wayne and discussed the reason for the visit. The LPA, along with facility Licensee Larry Wayne, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers were observed to be fully charged, but purchased over 12 months prior to today's visit. During the visit, Licensee purchased new fire extinguishers. Hardwired smoke detectors and separate carbon monoxide detector were tested at 06:10PM and were functional at the time of the visit. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. The backyard has a covered outdoor area equipped with furniture for resident use. Licensee indicated the residents do not use the backyard area. There were no bodies of water noted. The back patio did contain items being stored, however no hazardous items were observed and the passageways were clear from obstructions. The laundry room was observed to be locked and contained cleaning chemical storage, as well as storage for additional items. The garage was observed locked. KITCHEN : Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All sharp objects were observed to be locked and properly stored at Report Continued on LIC 809-C the time of the visit. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 2 (two) are currently occupied for resident use, 1 (one) is locked and being used for storage, and 2 (two) were observed locked and designated as staff rooms. RESTROOMS: The LPA noted there are 2 restrooms in the facility; one is designated for resident use and one is for staff use. LPA observed the resident restroom. Resident restroom was clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed the water temperature in the resident restroom to be 112.1 degrees Fahrenheit. RECORD REVIEW: Beginning at 12:40PM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 3 (three) of 3 (three) resident records reviewed were complete and contained all required documents. 2 (two) of 2 (two) staff files reviewed did not contain proof of CPR or first aid. MEDICATION REVIEW: Beginning at 05:19PM, LPA reviewed medications for 3 (three) of 3 (three) residents. The facility does not currently have centrally stored medication records, although all 3 (three) residents have medications the facility is storing and assisting in administering. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA spoke with the Licensee regarding the facility's Emergency Disaster plan and Infection Control Plan. To date, the facility has not submitted an Infection Control plan. LPA provided both the infection control plan template and the Emergency and Disaster plan template to the Licensee via email. INTERVIEWS: During today's visit, LPA interviewed facility staff and attempted to interview residents. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.