The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked storage container in the kitchen. Kitchen appliances were in operable condition. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food. Additional perishable food items were purchased prior to the visit and stored in the garage area on a shelf and/or an extra freezer. The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation. The Kitchen/food service and preparation area was very clean and everything appeared to be in good/operating condition.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is covered and inaccessible. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were fully charged and were last serviced October 2022. All exits from the facility either have delayed egress or locks which were all operational at the time of the visit. The LPA observed required postings throughout the common space. There were two linen closets in the hallway with extra towels and fresh linens for residents.

Continued on 809-C

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated resident rooms. One of the resident rooms has two beds and an attached bathroom. The other two resident bedrooms have individual beds, and the residents share a bathroom in the hallway. At the time of the visit, the facility has a designated staff room which also serves as an office for the licensee. Each closet in all of the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for future residents.

RESTROOMS: The two resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in both of the restrooms at the appropriate degrees Fahrenheit as per the regulations.

RECORDS: Resident records were not reviewed because at this time the facility is not licensed and does not have any residents occupying any of the bedrooms. Personnel records reviews were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All staff member personnel records had the appropriate documentation with no expiration of any training.

MEDICATIONS: Medications were not reviewed as there are no residents at the facility at this time, so there are no medications being stored at the facility. Medications will be stored in the future in a centrally stored and locked closet in the hallway. The LPA observed the Licensee demonstrate the locking and unlocking of the centrally stored medication cabinet in the hallway. Continued on 809-C

FACILITY DOCUMENTATION: The facility keeps hard copies of the LIC 200 Application for an RCFE, LIC 215 Applicant Information LIC 308, LIC 400 Affidavit Regarding Client/Resident Cash Resources, LIC 401 Monthly Operating Statement, LIC 402 Surety Bond, LIC 401(a) Supplemental Financial Information, LIC 403 Balance Sheet, LIC 404 Financial Information Release and Verification, LIC 500 Personnel Report, LIC 501 Personnel Record, LIC 503 Health Screening Report, LIC 610E Emergency Disaster Plan for Residential Care Facilities For the Elderly, LIC 9282 Residential Infection Control Plan, LIC 999 Facility Sketch, and the Rental Agreement signed and dated 04/01/2023 with a copy of Cashier’s Check. The facility additionally has a Plan of Operation, Control of Property, The Job Description for Each Staff Position, Personnel Policy, In-Service Training for Staff, Facility Program Description, Rules of Discipline/Personal Rights, Admission Agreement for Residents, Sample Food Menu, Theft & Loss Policy, Neighborhood Complaint Policy, Hazard Assessment, and Job Description for the Administrator. The facility has on file a Dementia Care Plan document as well as Hospice Care Waiver. The Hospice Care Waiver states the maximum number of Hospice residents which the facility is requesting at any one time is two (2).

No deficiencies cited. A Technical Assistance was noted on the LIC 610E as a licensee must list at least two appropriate shelter locations that can house facility residents during and evacuation and are equipped to provide safe temporary accommodations. One of the locations must be outside the immediate area where the facility is located. The Facility LIC 610E lists four temporary shelter locations, but all are within the immediate area. Licensee agreed to immediately change one of the temporary shelter locations to outside the area in Santa Maria, CA. Exit interview conducted. A copy of the report was issued.