Routine inspection·April 16, 2025

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:10 A.M. The LPA was greeted by Caregiver Kazim Albert. LPA informed the reason for the visit. Caregiver contacted the facility representative by phone, Laila Kulungu. At 10:35 A.M. facility representative arrived. At 10:37 A.M. Administrator, Yusuf Ibironke, was contacted by phone and informed of LPA’s visit. Administrator was unavailable during today's visit. Administrator stated that she not able come to the facility often due to distance, but authorized facility representative, to sign today's reports. Reason for the visit was stated. Entrance interview conducted. At 10:45 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 serviced 11/16/2023. During today’s visit, staff bought two (2) new fire extinguishers. At 11:22 A.M. the smoke detectors and carbon monoxide detectors are combined units; they were tested and functioned properly. Per facility representative there is a fire door to enhance safety and prevent the spread of fire. Continued on LIC 809-C Continued from LIC 809 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. Inside the cabinet LPA observed a low supply of emergency water, PPE, three (3) 1 st aid kits and other dry food supplies. LPA conducted a review of expiration dates on product labels. LPA observed sharps and knives locked in a kitchen drawer. At 10:53 A.M. hot water measured at 115.8 * F. Cleaning supplies are located in separate locked cabinets with additional supplies in the locked garage. Laundry Room: Adjacent to the kitchen, LPA observed a washer and dryer. All cleaning supplies and detergents were locked and inaccessible to residents. Garage: The Garage remains locked and inaccessible to the residents in care. LPA observed extra PPE supplies, cleaning supplies, two (2) refrigerators with extra food for staff and residents, and an office where staff and reside nt’s files are kept. 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. At 10:50 A.M., during the inspection, the LPA observed an unlocked hallway closet labeled as staff storage. Inside, LPA observed a two (2) drawer nightstand. Inside a drawer LPA observed a bottle of Cyclobenzapr 10MG (muscle relaxer). Facility representative immediately remove prescribed medication and locked it away. 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 being improperly held open by a string tied to the doorknob and secured to a metal hook that had been hammered into the wall. The administrator immediately closed the door during today’s visit and acknowledged that the door will remain closed at all times in compliance with fire safety requirements. Continued on LIC 809-C Continued from LIC 809-C BATHROOMS: Bathrooms were observed to be equipped with slip resistant surfaces and grab bars. Between 10:49 A.M. and 11:16 A.M. hot water temperature measured between 105* - 120 *F which was within the required range. BEDROOMS : There are four (5) private bedrooms and one shared bedroom. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. OUTDOOR SPACE: The backyard has a covered patio ar ea, however, no patio furniture was observed during today’s visit. Facility has one side gate; LPA observed the side gate to be self-closing and self-latching gate with clear passageways for emergency exit use. LPA observed a shed located in the backyard, there was mobility devices and b oxes with decoration items. Facility provides sufficient space to accommodate both indoor and outdoor activities. There were no bodies of water on the premises. RECORD REVIEW: Between 12:42 P.M. and 2:45 P.M., staff and resident records were reviewed. During the resident’s record review, LPA observed Resident #1 (R1) and Resident #2 (R2) and Resident #4 (R4) to be at risk if allowed direct access to personal grooming and hygiene items. LPA observed R4’s physician report not to have tuberculosis test result. All other records were observed to be complete. Additionally, R1, R2 and R4’s admission agreement did not have the admission date reflected on the main admission contract. Technical violation issued. Furthermore, LPA observed that R1 and R2’s needs and service plan was not updated. Technical Violation issued. During the staff’s record review LPA observed, all files to be complete. However, 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, facility representative associated S1. LPA requested facility administrator’s file for compliance, however, facility representative was unable to produce it. Continued on LIC 809-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 kitchen. Between 2:10 P.M. and 4:10 P.M. Medications for four (4) residents were observed. LPA observed two (2) medications for R1 was centrally stored at the facility, given as prescribed, and logged in the MARS but not logged on the Centrally Store Medication form. Technical Violation issued. Furthermore, LPA observed that R4’s 30-day supply of Famotidine 20MG had a handwritten “opened” date label indication 04/01/2025, written by facility staff. However, the original pharmacy label on the medication container showed a filled date of 11/21/2024. 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.