Routine inspection·April 2, 2025

At 10:00 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Ivy Sudjati arrived shortly thereafter. At 10:15 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: Facility is a single-story residence that consists of five (5) resident bedrooms, and three (3) restrooms (2 private and 1 communal). The LPA observed one (1) fire extinguisher which was fully charged and last serviced on 03/27/2025. At 10:44 a.m. all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings throughout the facility. Kitchen : The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are always available for the residents. 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 between 106.5 and 111.9 degrees Fahrenheit. Report will continue on LIC809-C. Common Areas: These included the living room and dining areas. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the TV room, which is covered with furniture and the TV. There were no obstructions and/or tripping hazards throughout the facility. The garage: The LPA observed the garage where additional supplies and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in the garage. Surrounding Grounds (Outdoors) : The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no open bodies of water on the premises. 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 1/10/2025). The LPA reviewed five (5) out of five (5) resident files and five (5) out of twelve (12) staff files. All files 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 stored in a locked cabinet in the laundry room and inaccessible to the residents. Medications were documented on the Facility Centrally Stored Medication and Destruction Record (CSMDR). During Resident #1 (R#1's) audit, the LPA observed a list of medications for R1, however several medications were not present. Upon observation, the administrator stated that the hospice agency has not sent them as they will be discontinued. During R2's audit. the LPA observed three (3) medications with the incorrect quantity of medications left based on the start dates and quantities on the CSMDR and the Medication Administration Record (MAR). In addition R1 has gone 2 to 3 days without one of their medications due to it not being refilled on time. I nterviews: The LPA conducted two (2) staff and two (2) resident Interviews, attempted to conduct a third resident interview however the resident was sleepy. 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.