Routine inspection·June 17, 2024

Licensing Program Analysts (LPAs) Kelly Dulek and Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 11:01AM. LPAs met with Licensee/Administrator Jennifer Shaffer. Entrance interview conducted. Beginning at 11:15AM, the LPAs, along with Licensee/Administrator 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 extinguishers are fully charged and recently serviced on 04/03/2024. Hardwired combination smoke and carbon monoxide detectors and fire door were tested at 12:45PM and all were functional at the time of the visit. No fire clearance concerns were observed. BEDROOMS : There are 5 (five) total bedrooms in the facility; 2 (two) are designated as shared rooms, 2 (two) are designated as private resident rooms and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Room #1, which belongs to Resident #1 (R1) was observed to have full bed rails. Room #4, belonging to Resident #2 (R2) contained unsecured Advil in the resident's drawer. Staff room was observed to be locked. BATHROOMS : There are 2 (two) bathrooms for resident use. 1 (one) is designated for shared resident use and the other 1 (one) is a private resident restroom. 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 both resident bathrooms and measured within the required range. COMMON AREAS : This includes the living room and dining room areas. LPAs observed common area to be clean and properly furnished at the time of the visit. A fireplace was observed in the living room and was inaccessible to residents in care. Exit doors contain alarms and were functional at the time of the visit. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs Report Continued on LIC 809-C for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. An outdoor shed was observed to be locked and inaccessible to residents. KITCHEN/GARAGE : The LPAs observed the garage to be locked and contain cleaning supplies, knives, emergency food, additional refrigerator/food storage, as well as supplies and laundry machines. Kitchen was observed 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. Cleaning supplies are located in a locked under-sink cabinet. Medications were observed to be in a locked kitchen cabinet. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs 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 is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 04/03/2024. RECORD REVIEW: 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. Review of R1's file revealed that R1 is not on hospice and R1 does not have a valid exception on file. Review of R2's file revealed that R2 cannot store their own medications. 5 (five) staff files observed contained all documents. MEDICATION REVIEW: Medications for 2 (two) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. INTERVIEWS: During today's visit, LPAs interviewed 2 (two) staff and 2 (two) residents. During today's visit, LPAs obtained a copy of the facility's liability insurance. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.