Routine inspection·July 5, 2024

Licensing Program Analysts (LPAs) Trevor Byrne and Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 08:58AM. LPAs were greeted by staff who contacted Facility Designee Arnida Obtinalla who arrived at the facility at approximately 09:00AM. Entrance interview conducted. Beginning at 09:00AM, the LPAs, along with Facility Designee 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 : The LPAs observed the kitchen/dining area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food and emergency water. The LPAs observed one designated cabinet where knives and sharps are stored locked and inaccessible to residents. Cleaning supplies are located in a locked cabinet under the kitchen sink. LAUNDRY & GARAGE : The laundry room is located adjacent to the kitchen. Laundry supplies and chemicals are stored in a locked cabinet, inaccessible to residents in care. Garage was observed locked and contained an additional freezer and pantry, which contained adequate emergency supplies. 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. Fireplace was noted to be screened and inaccessible to residents. The LPAs observed the fire extinguisher to be fully charged and purchased on 05/29/2024. Hardwired smoke detectors and carbon monoxide detectors were tested at 09:31 AM and were functional at the time of the visit. Report Continued on LIC 809-C Continued from LIC 809 BEDROOMS : There are five (5) bedrooms in the facility; four (4) bedrooms are designated for resident use, including two (2) shared rooms, and two (2) private rooms, as well as one (1) staff room. The staff room is kept locked. All 4 (four) resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. BATHROOMS : There are two (2) bathrooms for resident use, one (1) of which is a shared resident restroom located in the hallway and one (1) 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 the shared resident bathroom to be 114.8 degrees at 09:18 AM. The water temperature in the private bathroom was measured to be 118.6 degrees at 09:29 AM. Both restrooms were measured to be within the required range. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. Facility has two total gates, one (1) gate was observed to be self-latching and closing with clear passageways for emergency exit use. There were no bodies of water on the premises at the time of the visit . RECORD REVIEW: Began at 09:37AM. 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. MEDICATION REVIEW: Began at 10:15 AM. Medications for three (3) of five (5) residents were observed. One (1) resident (Resident 1 – R1) had PRN (as needed) medications prescribed. The doctor for R1 indicated that the resident can not communicate their need for the medication. Based on record review the facility lacked a record of the times the physician was contacted to administer these medications. Report Continued on LIC 809-C Continued from LIC 809-C 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. Last emergency disaster drill was conducted 04/27/2024. INTERVIEWS: LPAs interviewed two (2) staff and three (3) residents. The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Licensee was advised that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.