The facility is licensed to operate for a capacity of six (6) residents of which five (5) nonambulatory residents and of which one (1) may be bedridden. The facility has a hospice waiver for three (3) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) Staff Bedroom, two (2) bathrooms, living area, dining area, kitchen, outdoor covered patio, and an attached two car garage.

LPA Kim toured inside and outside of the physical plant with AD Tesfay. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, Resident Room 4, Resident Room 5, and Staff Room. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 114.9 degrees F. A comfortable temperature of 73 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food is stored in kitchen pantry, emergency water and emergency supplies are stored in the garage. The facility has two (2) fire extinguisher that were charged and mounted in the living area and resident hallway.

Evaluation Report Continues on LIC 809-C

LPA Kim conducted an audit of resident files (R1-R6), staff files (S1-S2), and medication and medication administration review. LPA Kim conducted one (1) staff interview.

A deficiency was cited during this visit as per Title 22 Division 6 Chapter 8 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Saba Tesfay.