Routine inspection·December 21, 2023

At 09:10 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrator Sean Beharry and informed them of the reason for the visit. At 09:35 a.m. the LPA conducted a tour of the physical plant with Administrator Sean to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a double-story residence that consists of twenty-five (25) resident rooms, seven (7) half bathrooms, five (5) full bathrooms, activity room, common sitting area, dining room, and kitchen on the first floor. The second floor consists of three (3) staff rooms, one (1) office and is only for staff use and inaccessible to resident in care. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 02/07/2023. Smoke alarms and carbon monoxide detectors were tested and functioned properly. Kitchen : During the facility tour at 9:36 a.m., kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Bedrooms: During today’s visit, the LPA observed ten (10) randomly selected resident units. The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding. At 11:07 a.m. the LPA observed a camera in room #17. The Administrator stated that the responsible party requested a baby monitor to be placed in the resident’s room (R1) due to R1 being a fall risk. The baby monitor was removed from R1’s room during the visit. At 10:49 a.m. the LPA observed a dresser and a nightstand with missing knobs in room #20 and the floor to be unkept with residue. At 10:55 a.m. the LPA Observed a nightstand with missing knobs in room #21. Report will continur on LIC809-C. Bathrooms: T he LPA toured five (5) of twelve (12) resident bathrooms and checked to make sure bathrooms were clean and in good repair. The LPA observed appropriate grab bars and non-skid mat and/or material in each bathroom. Water temperature was tested randomly in bathrooms. The water temperature measured in the restrooms ranged between 124.0 degrees Fahrenheit and 127.5 degrees Fahrenheit between 10:07 a.m. and 10:33 a.m. Common Areas: These included the dining areas and activity room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Record Review: At 12:15 p.m. a review of facility files was initiated. The LPA reviewed five (5) of twenty four (24) staff files. Out of the five files reviewed, the LPA identified that one out of five staff (S1) does not have any annual training on file, and three out of five staff (S2, S3, S4) are missing 15.5 annual training hours including four (4) hours of which shall be specific to postural supports, restricted health conditions, and hospice care. Otherwise, the staff files were in order. Interviews: During today’s visit, the LPA conducted four (4) resident interviews. No concerns voiced during the interviews. Due to time constraints the LPA will return to complete the annual at a later date. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator Sean Beharry.