Routine inspection·March 8, 2023

Licensing Program Analysts (LPAs) Kelly Dulek and Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 12:16PM. LPAs were greeted by the Licensee, Esmeralda Ocampo-Nunez. Entrance interview conducted. At 12:25PM, the LPAs, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: The LPAs observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The facility consists of 5 (five) total bedrooms, 3 (three) are designated for resident use and 2 (two) are designated for staff use. Staff bedrooms were observed locked. 1 (one) staff room has a restroom, but it is not currently permitted. The Licensee indicated she is working with a contractor who will be obtaining proper permits. RESTROOMS : Observed beginning at 12:26PM, restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 12:26PM, LPAs observed disinfecting wipes under the sink in the shared resident restroom, accessible to residents in care. At 12:30PM, hot water measured at 120.0 degrees Fahrenheit in the common resident restroom and at 12:35PM, hot water measured at 119.4 degrees Fahrenheit in the private resident restroom. At 12:35PM, LPAs observed Glade Air Freshener in the private resident restroom, accessible to residents in care. COMMON AREAS : The LPAs observed common area to be relatively clean and properly furnished at the time of the visit. The LPAs observed the fire extinguishers to be fully charged and last serviced on 12/14/2021. During today's visit, the fire extinguishers were serviced and tags updated with the current date. Continued on LIC 809-C At 03:55PM, fire alarms and carbon monoxide detectors were tested and functioned properly. The temperature was maintained at a comfortable level. Cleaning supplies and disinfectants are stored in the locked file cabinet near the laundry room. The LPAs observed cameras in the common areas, as well as the backyard. KITCHEN: At 12:49PM, he LPAs observed the kitchen/dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. OUTDOOR SPACE: At 12:55PM, the LPAs observed the backyard, which has a covered outdoor area for resident use. There are no bodies of water noted. Knives and sharp items are stored in a shed in the backyard. At 12:55PM, LPAs observed locks present on the shed containing sharps, however the locks were not engaged, rendering the knives accessible to residents in care. At 12:56PM, LPAs observed 2 (two) gates on both sides of the facility were not self-closing. LPAs also observed Mr. Clean disinfecting wipes on the outside patio, accessible to residents in care. The garage was locked and attached to the house. RECORD REVIEW: Began at 01:03PM, 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. 1 of 1 staff files reviewed contained all required documents. 2 additional volunteer/staff files were reviewed. Currently, the additional workers are designated as volunteers and meet volunteer requirements, however, do not meet all staff training requirements. One (1) of one (1) resident records reviewed was observed to be complete at the time of the visit. MEDICATION REVIEW: Began at 03:13PM. Medications for one (1) of one (1) resident was observed. Prescription medications reviewed were documented and labeled in accordance with regulation. However, five (5) of five (5) over the counter medications were not labeled per regulation. Additionally, 4 (four) of 5 (five) over the counter medications (Vitamin D3, Folate, B12, and Vitamin C) did not have prescription orders. INFECTION CONTROL: During today’s visit, the LPAs spoke with the Licensee regarding the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate. Report Continued on LIC 809-C INTERVIEWS: Beginning at 04:54PM, LPAs interviewed 2 (two) staff and 1 (one) resident. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report was provided.