Routine inspection·February 21, 2025

Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 11:15 a.m. LPA was greeted by staff, and staff contacted the Administrator via telephone to inform them of the visit. Administrator Roberto Ramirez arrived at approximately 3:00 p.m. At the time the LPA arrived there were four (4) residents present, during the visit a fifth resident was admitted to the home. Record Review: At 11:20 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet. The LPA observed documentation of Disaster prevention and last Disaster drill (conducted on 1/20/2025). The LPA obtained Resident Roster, Staff Roster and Insurance liability. The LPA reviewed four (4) out of five (5) resident files and the following was observed: Three residents (R1, R2, R3) did not have the Identification and Emergency Information form (LIC601) and a signed Residents Personal Rights form (LIC613) on file. R2 ’s file contained a positive TB test. No chest x-ray was present at the time of the file review. The LPA reviewed four (4) out of five (5) staff files as one (1) staff's (S1's) file was missing. Additionally, S1 is not associated to the facility. There was no annual training on file for S2. S3 who was present during the visit is also not associated to the facility. At 1:30 p.m. the LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Carbon monoxide and smoke alarms were tested and functioned properly. The fire extinguisher appeared fully charged and was last serviced on 1/3/2025. BEDROOMS: The resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Two bedrooms are share bedrooms, and two are single occupancy. There is also a staff room. Report will continue on LIC809-C, 2nd page. (continued from 809) RESTROOMS: There are two restrooms for resident use. Restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. The LPA did not observed soap in both restroom. Hot water temperature was within regulatory requirements (105*F-120*F); it was measured at 108.3*F. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common hallway. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Laundry room was locked and contained storage cabinets for laundry supplies. The garage was observed locked. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Medications: Medications review began at 2:40 p.m.; medications are centrally stored and locked in a cabinet near the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. INTERVIEWS: LPA interviewed two residents and one staff; no concerns noted. 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 Administrator.