Routine inspection·June 11, 2024

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 11:35AM. LPA initially met with facility staff. Licensee Cilva Toume was contacted over the telephone and arrived at 12:37PM. Entrance interview conducted. Beginning at 12:48PM, the LPA, along with 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 : Fire extinguisher is fully charged an d purchased on 05/23/2024 . Smoke detectors were tested at 02:39PM, Carbon Monoxide detector was tested at 02:40PM. A l l were functional at the time of the visit. BEDROOMS : There are 8 (eight) total bedrooms in the facility; 6 (six) bedrooms are designated for resident use, 1 (one) staff room and 1 (one) room is utilized for storage. The staff room is kept locked and the storage room did not contain any hazardous items. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. LPA observed full bedrails on 2 (two) residents' beds, however these residents (Resident #1 - R1 and Resident #2 - R2) are not on hospice and do not have valid exceptions on file with the Department. BATHROOMS : There are 3 (three) total bathrooms in the facility. 1 (one) is used for staff, 1 (one) is a private resident bathroom, and 1 (one) is a hallway bathroom designated for shared resident use. Resident restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in shared resident bathroom and measured in compliance with regulation. COMMON AREAS : This includes the living room and dining room areas. LPA observed common area to be Report Continued on LIC 809-C clean and properly furnished at the time of the visit. LPA observed a door stop installed on the fire door in the common area leading to the resident bedrooms. Fire clearance indicates "door stops are prohibited." Medications are stored in a locked hallway cabinet. KITCHEN : The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Knives are stored in a locked box in the kitchen. GARAGE : Garage was observed locked and contained laundry area, locked chemical storage, extra food, supplies, and emergency food and water. OUTDOOR SPACE: The backyard has a shaded patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. RECORD REVIEW: LPA reviewed 3 (three) resident files during today's visit. R1 and R2 do not have valid exceptions on file. Staff files and additional resident files will be reviewed during annual continuation visit. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan was observed to be complete and updated annually, as required. MEDICATION REVIEW: Will be observed during annual continuation visit. INTERVIEWS: During today's visit, LPA interviewed 1 (one) resident. Additional interviews will be conducted during the annual continuation visit. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Civil penalty issued in the amount of $500. Licensee was informed that failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.