Routine inspection·October 25, 2023

Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced Required - 1 Year inspection at the facility today. LPA met with administrator Ivy Sudjati and explained the reason for the visit. The LPA 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: KITCHEN : The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen. Cleaning supplies and items that could pose a danger were secured in locked cabinets. The facility has a supply of emergency food and water. The water temperature was measured at 135.1*F which is over the temperature allowed of 105*F - 120*F. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and condition. All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The fire extinguisher was fully charged and last serviced on 4/19/2023. The carbon monoxide detector and smoke detectors were tested and were operational. Medications are centrally stored and in a locked cabinet in the laundry room. Cleaning supplies were observed to be locked in the laundry room and inaccessible to residents in care. The backyard has covered seating for resident use. Fireplace in the living room lacked a screen. BEDROOMS: There are four resident bedrooms and two staff bedrooms. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report continued on LIC 809-C. RESTROOMS: The facility has two common restrooms for residents' use. There is half bathroom for guests and one restroom for staff. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. The hot water temperature in the common hallway restroom measured at 140.2*F which is over the temperature allowed of 105*F - 120*F. MEDICATIONS: Medications are locked and centrally stored in a locked cabinet in the laundry room area. LPA reviewed medications and they appear to be given as prescribed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. RECORDS: Resident files reviewed were found to be complete. Three staff files were reviewed and also found to be complete. Disaster drills are conducted quarterly. The facility has a 30 day supply of personal protective equipment and an emergency disaster plan on file. The updated liability insurance policy was provided to LPA during the visit. INTERVIEWS: Interviews were conducted with one staff and attempted with one resident. No issues or concerns revealed. 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 to the administrator.