Community Care Licensing
Document Has Been Signed on 07/31/2025 07:57 PM - It Cannot Be Edited
The facility is fire cleared for two non-ambulatory rooms (one shared and one private room) located on the first floor of the facility (total capacity of three (3) non-ambulatory residents). The Fire Clearance was approved on 05/01/2024.The LPA and Staff 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.
Report Continued on LIC 809-C PAGE 2...
The last emergency disaster drill took place last year sometime the exact date is unknown. LPA advised the importance of staying in compliance by conducting quarterly drills and Staff agreed to conduct a drill today 07/31/2025. Activities were observed in the common areas. There is a functioning telephone on the premises.
INTERVIEWS: Starting at 10:15 a.m. one (1) staff, one (1) volunteer and two (2) resident interviews were conducted. Staff and volunteer interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit.
BEDROOMS: There are three (3) total bedrooms in the facility; two (2) bedrooms on the first floor (designated for residents) and one (1) bedroom upstairs for the operators/staff. Of the two (2) resident bedrooms one (1) is designated as private, single occupancy, resident room and one (1) is designated as a shared double occupancy resident room. The upstairs staff room and area is kept locked at all times. The stairway leading to the staff area and staff room is locked with a gate. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: There are two (2) total restrooms in the facility of which one (1), on the first floor is designated as a shared / common resident restroom, and one (1), on the second floor is designated as a staff restroom. Resident restroom was observed to be equipped with a slip resistant mat. Grab bars were observed in the restroom. The restroom was sufficiently stocked with supplies and paper towels. The hot water temperature was measured in the resident restroom and measured 110.2 degrees Fahrenheit, within the required range. LPA observed storage space closets in hallway containing extra clean linens and towels for resident use.
KITCHEN: The LPA inspected the kitchen/food service area at 10:56 a.m. The kitchen faucet was measured for hot water temperature, and it measured 109.2 degrees Fahrenheit at 10:58 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 11:05 a.m. LPA and staff observed an unlocked medication, on the door shelf which was accessible which poses/posed a potential health, safety or personal rights risk to persons in care. Report Continued on LIC 809-C PAGE 3...
Staff informed LPA that the medication belonged to the Administrator. The label on the medication confirmed it belonged to Administrator, Victor Heredia and at the time of the visit was relocated to the staff refrigerator upstairs in the locked room. Cleaning supplies and other chemicals are kept locked under the sink inaccessible to residents in care. At 11:08 a.m. LPA and staff observed a lighter and matches in one of the drawers which were accessible which poses/posed a potential health, safety or personal rights risk to persons in care.
BACKYARD: The entire property is fenced. The backyard has a patio area with an umbrella for shade, patio furniture including a table and chairs for resident use. LPA observed the backyard of the facility to contain a pool that was completely fenced. At 11:16 a.m. LPA observed the gate to the pool to be unlocked and accessible to residents in care at the time of the inspection. LPA informed the Licensee Representative that an accessible body of water is a zero-tolerance violation and an immediate civil penalty in the amount of $500 will be assessed on today’s date (07/31/2025).The Licensee Representative stated they must have put the lock on wrong and at the time of the visit locked the gate properly. All passageways were observed to be clear. LPA observed two (2) self-latching gates. There are two (2) locked storage sheds in the back yard inaccessible to residents. Only 1 (one) pathway is used as an emergency exit which was free of obstructions at the time of the visit.
GARAGE: The garage is detached to the house and remains locked at all times. The laundry room containing a washer and dryer are inside the garage. Detergents, disinfectants, and cleaning supplies observed locked and inaccessible in the garage.
RECORDS: Record review began at approx. 11:35 a.m.
Resident Records were reviewed beginning at 11:36 a.m. two (2) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Record review revealed that R1 was missing LIC 613C, LIC 621, PRN Authorization Letter, R2 was missing LIC 601 and PRN Authorization Letter which poses/posed a potential health, safety or personal rights risk to persons in care. At the time of the visit R2's physician had a scheduled on site visit and completed the PRN Authorization Letter.
Report Continued on LIC 809-C PAGE 4...
Personnel Records were reviewed beginning at 1:32 p.m. two (2) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Record review revealed that S1 was missing finger print clearance letter, LIC 503 Health screening report with TB results. S2 was missing finger print clearance letter, LIC 503 Health screening report with TB results, initial training, annual training and medication training which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee Representative stated they have all the required documentation however was unable to find it at the time of the visit. At 1:56 p.m. record review and interview revealed that Volunteer #1 (V1) has volunteered at the facility for about a year and has not been associated to the facility. The LPA reviewed the Guardian website and discovered that V1 was observed to have fingerprint clearance but was not associated to the facility. LPA informed the Licensee Representative that volunteers must obtain a fingerprint clearance and be associated to the facility prior to working, residing or volunteering in a licensed facility. LPA informed the Administrator that a civil penalty in the amount of 500$ (1 Employee x 100$/day x 5 days [maximum of 5 days] = $500) will be assessed on today’s date (07/31/2025) for not having submitted a criminal record clearance transfer request for V1. At the time of the visit the volunteers file was unavailable, however staff stated that they have TB results, CPR/FA and background check and will submit proof once they find it.
INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. The facilities policies and procedures, as they pertain to infection control and emergency planning, are satisfactory.
MEDICATIONS: Medication review began at approximately 4:25 p.m. Medications are centrally stored and locked in a cabinet in the kitchen adjacent to the dining room. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. At 4:30 p.m. LPA and Licensee Representative observed R2's medication to not be documented correctly on the centrally stored medication and destruction record missing the prescription number which poses/posed a potential health, safety or personal rights risk to persons in care.
Report Continued on LIC 809-C PAGE 5...
DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster and LIC 9020A Resident roster and copy of the Limited Liability insurance.
Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Two (2) Civil penalties were issued in the amount of $500 each with a total of $1000. Administrator was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.