Routine inspection·May 2, 2025

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced annual inspection at the facility today and met with Administrator Ivy Sudjati. Entrance interview conducted. At 10:45 a.m. the LPA conducted a tour of the physical plant with the Administrator to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: The facility is a single-story home, which consists of 5 (five) bedrooms and 4 (four) bathrooms. There is no staff room and staff will remain awake at night.. The LPA observed one (1) fire extinguisher which was fully charged and last serviced on 03/27/2025. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed the required postings in the entry way and common sitting area. KITCHEN/FOOD SERVICE AREA: The facility has a sufficient supply of non-perishable foods, emergency food and water. Knives and sharp items are stored in a locked box. Cleaning supplies and disinfectants are stored underneath the locked kitchen sink and in the locked garage. The facility has a sufficient supply of plates, cups and utensils. RESIDENT BEDROOMS: All resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. The hot water temperature in resident restrooms measured at 117 degrees Fahrenheit. Report will continue on LIC809-C. COMMON AREAS: The sitting area/activity room, family/television room, and dining area are furnished appropriately.The facility has a laundry closet located in the office area, which contains an operational washing machine and dryer. LPA observed cameras in common areas. OUTDOOR SPACE: The back yard area is enclosed. Both gates were observed to be self-closing and self-latching. The backyard contains a shaded seating area and appropriate outdoor furnishings, as well as outdoor activity supplies. Backyard contains a storage shed. There are no bodies of water on the premises. The backyard contains access to a locked garage. LPA observed the garage to contain extra cleaning supplies, storage and paper goods. Record Review: At 11:00 a.m. a review of facility files was initiated. The LPA obtained documentation of Resident and Staff Rosters, Infection Control, Disaster prevention and last fire drill (conducted on 1/16/2025). Initial Staff Roster indicated there were fourteen (14) staff working for the facility, LPA verified fingerprinted clearance and association for the staff with LIS list and Guardian. The Guardian Portal revealed that Staff 1 (S1) was not associated to the facility. Administrator revealed that S1 no longer works at the facility and their last day was 04/26/25. The LPA reviewed five (5) out of five (5) resident files and five (5) out of twelve (10) staff files and the following was observed: Resident (R1) did not have a negative TB test on file, otherwise all records were complete and current Medications: At 1:00 p.m., a medications review was initiated for two out of five residents and the following was observed. The medications were centrally stored in a locked cabinet in the common sitting area. During Resident #2 (R#2's) audit, the LPA observed one (1) medication not documented on the Centrally Stored Medication and Destruction Record (CSMDR) and four (4) medications documented incorrectly. During R3's audit. the LPA observed three (3) medications not documented on the CSMDR, and one medication documented incorrectly. I nterviews: The LPA attempted to conduct three (3) resident interviews. No immediate concerns were voiced. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to the Administrator.