Routine inspection·May 19, 2025

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:15 A.M. The LPA was greeted by Caregiver Romeo Thompson. LPA informed the reason for the visit. Caregiver contacted the facility representative by phone, Laila Kulungu. At 10:55 A.M. facility representative arrived. Administrator, Yusuf Ibironke, was unavailable during today's visit and does not come to the facility often due to distance, however, authorized facility representative, to sign today's reports. Reason for the visit was stated. Entrance interview conducted. At 11:10 A.M. LPA conducted a physical plant tour inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Fire extinguisher was last purchased 04/16/2025. Between 11:32 A.M. and 11:39 A.M. two (2) carbon monoxide detectors and the hardwired smoke detectors were tested and functioned properly. According to facility representative, the door connecting the common area to the wing where rooms one (1) through four (4) are located is designated as a fire door. This door is in place to enhance safety and prevent the spread of fire. Continued on LIC 809-C Continued from LIC 809-C KITCHEN : The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Additional non-perishable food supplies were observed inside a cabinet adjacent to the kitchen. LPA conducted a review of expiration dates on product labels. LPA observed sharps and knives locked in a kitchen drawer. At 11:20 A.M. hot water measured at 117.2 * F. COMMON AREAS : This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 72 degrees. LPA observed a working phone available for residents. The LPA observed the required postings in the common area and a fireplace was observed adequately screened. During the inspection, the LPA observed a fire door held open by a magnet; however, when the smoke detectors were tested, the fire door did not release and close as expected. The administrator immediately closed the door during today’s visit and acknowledged that the door will be maintained closed at all times or the wiring connecting the fire door to the smoke alarms should function properly in the event of a fire to be in compliance with fire safety requirements. Cleaning supplies are located in a separate cabinet next to the main entrance. LPA observed the door to be secured with a deadbolt lock which does not requires a key to unlock. Per facility’s representative, a handyman is scheduled to install a keyed entry deadbolt. BATHROOMS: There are two and a half (2 1/2) shared restrooms in the facility. All restrooms were observed to be clean and sanitary and in operating condition. Showers were also observed to have grab bars and slip resistant mats and surfaces with sufficient amounts of soap and paper products in each restroom. The LPA observed low pressure from the faucet located in the bathroom of room #3, as well a broken toilet paper dispenser in the hallway’s shared bathroom. Water temperature was measured in all shared restrooms and measured within the required range. Continued on LIC 809-C Continued from LIC809-C BEDROOMS : The facility has five (5) bedrooms total; one bedroom is shared, and the rest are private. The den is used as a staff room and remains locked. All resident bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linen, towels and paper products. LPA observed a broken electrical outlet in vacant room #5, also, Resident #1(R1), a hospice recipient, had full rails on their bed. LAUNDRY ROOM: The facility's laundry room is connected to the home but only accessible from outside. Laundry supplies are kept inside the locked closet in the house. GARAGE: The Garage remains locked and inaccessible to the residents in care. LPA observed extra PPE supplies, cleaning supplies, a refrigerator with extra food for staff and residents and mobility devices. OUTDOOR SPACE: The backyard has a covered patio which had shade and seating areas for residents to enjoy. Facility has three (3) side gates. LPA observed all gates to be self-closing and self-latching gates with clear passageways for emergency exit use. Facility provides sufficient space to accommodate both indoor and outdoor activities. There were no bodies of water on the premises at the time of the visit. RECORD REVIEW: Between 12:45 P.M. and 2:17 P.M., staff and resident records were reviewed. During the resident’s record review, LPA observed Resident #1 (R1) to be at risk if allowed direct access to personal grooming and hygiene items. All other records were observed to be complete. However, all residents were missing authorized representative’s signatures on their Needs and Service Plan. During the staff’s record review LPA observed, all files to be complete. LPA requested facility administrator’s file for compliance, however, facility representative was unable to produce it. According to our records, administrator’s certificated expired on 01/16/2025 and no renewal applications have been received at this time. Licensee is working to get a new administrator assigned to this facility. Additionally, a comparison of the LIC 500 (Personnel Record) and the Guardian System reflected that Staff #1 (S1) was fingerprinted but not associated to the facility. During today’s visit, Licensee associated S1. Continued on LIC809-C Continued from LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill documented on 04/06/2025. MEDICATION REVIEW: Locked medication cabinet is in the dining room and the kitchen. Between 2:10 P.M. and 3:20 P.M. Medications for four (4) residents were observed. LPA observed prescribed medications for Resident #2 (R2) -Bumetanide 2MG Tablet (16qty)- to be taken twice a daily. The Centrally Stored Medication Log indicates a start as of 05/01/2025. However, medication count in the bubble pack did not match the expected quantity bases on the prescribed dosage and start date. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.