Routine inspection·July 26, 2023

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced for a required 1-year annual inspection today at 10:00 a.m. Upon arriving at the facility, the LPA was scanned and greeted at the door by Administrator Marebeth Mallare and was explained the reason for the visit. At 10:15 a.m., the LPA, along with the 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: KITCHEN: At 10:18 a.m., the LPA observed the kitchen/dining area. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:25 a.m., LPA observed perishable food items in the refrigerator to be expired such milk, yogurt, hummus, cheese, dressings, dates of expiration ranged from Dec 28, 2022, up to Jul 25, 2023. The Administrator was advised to monitor perishable items for expiration. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The facility consists of 6 (six) total bedrooms, 4 (four) are designated for resident use and 2 (two) are designated for staff use. Staff bedrooms were observed and were occupied by staff. RESTROOMS : Observed beginning at 10:38 a.m., restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 10:39 a.m. and 10:45 a.m., hot water measured at 109.9 and 119.8 degrees Fahrenheit in the resident restrooms. COMMON AREAS : The LPA observed common area to be relatively clean and properly furnished at the time of the visit. The LPA observed the fire extinguishers to be fully charged and last serviced on 1/15/2023. Continued on LIC 809-C PAGE 2 At 11:33 a.m., fire alarms and carbon monoxide detectors were tested and functioned properly. The temperature was maintained at a comfortable level of 76 degrees F. Cleaning supplies and disinfectants are stored in the locked cabinet in the laundry room. OUTDOOR SPACE: At 10:56 a.m., the LPA observed the backyard, which had a covered outdoor area for resident use. There was an additional covered outdoor area for resident use in the front porch with two shaded benches and additional shaded seating. There are no bodies of water noted. LPA observed a detached garage with miscellaneous storage and supplies. LPA observed 2 (two) gates on both sides of the facility which were self-closing and self-latching only one is used as an emergency exit as was free of obstruction. RECORDS: Residents’ records review began at 11:45 a.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 12:25 p.m.; medications are centrally stored and locked in a cabinet in the dining room. Medications are labeled and checked for expiration dates. Medications were not properly documented on the centrally stored medications record as multiple medications were found not to be logged in for Resident #1 (R1) and Resident #2 (R2). Administrator stated that medications are not logged in until started. LPA advised Administrator that all medications should be logged in when received. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Report Continued on LIC 809-C PAGE 3 The LPAs obtained the following documents: - LIC500 Personnel Report - LIC9020 Client Roster 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.