Routine inspection·June 18, 2024

Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced annual visit to this facility at 10:00 a.m., LPA met with backup Administrator Harold De Guzman. Administrator was contacted via telephone and arrived at 11:09 a.m. Entrance interview conducted. Beginning at 11:12 a.m., the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three (3) total bedrooms, all of which are designated for shared resident use, at the time of the visit only Room #1 is being shared. During the physical plant tour, LPA observed trash cans not to have appropriate waste receptacle with a tight-fitting cover. LPA explained to Administrator the importance of such lids to prevent cross contamination. RESTROOMS: The LPA observed two (2) restrooms in the facility; one (1) is a shared restroom, and one (1) is a private restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 11:38 a.m. and 11:45 a.m., hot water was measured. All bathrooms were within the required limit of 105-120 degrees Fahrenheit. Continued on IC 809C Continued from LIC 809 COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room was observed to be in good condition. The LPA observed the required postings in the common area. Hardwired combination smoke and carbon monoxide detectors were tested by staff at 10:26 a.m. and were functional at the time of the visit. Fire extinguishers were observed to be fully charged and last serviced on 05/22/2024. The facility maintained a comfortable temperature of 75 degrees. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete. Emergency disaster drills are being conducted quarterly. KITCHEN : During the inspection, LPA observed inside refrigerator to be stained and the kitchen floor to have crumbs and not clean. LPA explained the importance of mopping regularly and having the facility clean, safe, sanitary and in good repair at all times. Also, at 11:15 a.m., LPA observed Allergy relief medication and an unknown bottle of medication without a label along with oatmeal, cookies, tea bags, coffee and baby food in an unlocked kitchen cabinet. Knives and other sharps were observed locked in a kitchen drawer. Cleaning supplies were observed in a locked under-sink cabinet. At 11:27 a.m., hot water measured at 122.9 degrees Fahrenheit. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. OUTDOOR SPACE: The side yard has a covered outdoor area equipped with furniture for resident to enjoy. There were no bodies of water noted. Continued on LIC 809C Continued from LIC 809C RECORD REVIEW: Began at 12:01 p.m., 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. Three (3) out of four (4) resident records reviewed were complete and contained all required documents. Resident # 1 (R1) records were missing ID form, Needs and service plan, consent form and Preplacement Appraisal form. At 2:00 p.m., five (5) staff files including the administrator were reviewed; Staff #1 (S1) and Staff #2 (S2) record’s had TB test results read by the licensee, Jocelyn Manacap. LPA read regulation 87411(f) from Title 22, Division 6, Chapter 8 Article 7 under Personnel Requirements-General where specifies that a physician shall perform such tests. Furthermore, during the course of the visit and reviewing records with administrator, LPA observed that Staff #2 (S2) is fingerprint cleared but not associated to the facility. Interview with Administrator and documents reviewed reflected S2 has been working in the facility as a backup caregiver since 10/10/2023. GARAGE: The garage was observed locked. LPA observed extra non-perishable food, and a refrigerator with extra food. Furthermore, laundry area, as well as emergency food supply and water, and storage space was observed in the garage. All cleaning compounds were stored in areas separately from food supplies. Additionally, at 11:14 am, LPA observed several garage storage cabinets with clothes and a chest of drawers full of clothes along with a queen bed with bedding sheets and a sofa bed with sheets and pillows in the garage. Administrator stated that this home used to be where they reside, and they are looking to move to a bigger apartment, until then the staff is using the garage as storage. Administrator stated that S2 works every Friday and Saturday from 7 a.m. to 7 p.m. and brings son along. During today visit staff and administrator stated that when tired they will use common areas to sleep. LPA reminded that during work hours staff primary focus should be the residents. LPA also informed administrator that given that there are no staff rooms, the facility is required to have 24/7 care and that staff cannot use common areas to sleep. LPA requested that the administrator clear all hazards from the garage and submit proof to licensing. Continued on LIC 809C Continued from LIC 809C MEDICATION REVIEW: All medications are kept in a hallway closet. This closet is locked at all time and medication are inaccessible to residents. LPA observed a complete 1 st aid kit including its manual inside that closet. Audit began at 3:21 p.m. Medications for all residents were observed to be in compliance with Title 22. Physician's Reports indicate Resident #2 (R2) is able to store and administer their own medications. As thus, the facility centrally stores medications for daily administration. INTERVIEWS: Throughout today's visit, LPA interviewed two (2) staff and one (1) resident. No immediate health or safety concerns noted. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report was provided.