Beginning at 9:50AM, the LPA, along with the Caregiver and Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher was last purchased 05/16/2024. Hardwired smoke and carbon monoxide detectors were tested at 10:06AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were off, however, staff turned them on and were functional at the time of the visit.

KITCHEN: LPA inspected the kitchen at 9:50AM. Knives are locked in a drawer next to the sink and cleaning supplies are stored inaccessible in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of 2 (two) days perishable and 7 (seven) days non-perishable food. Food was stored at appropriate temperatures.

BEDROOMS: There are 4 (four) total bedrooms in the facility; 2 (two) are designated as private resident rooms and 2 (two) are designated as shared rooms. Bedrooms #1 and #4 have exits to the exterior and attached bathrooms. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linens; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Report Continued on LIC 809-C

COMMON AREAS: This includes the living room and dining area in the kitchen. LPA observed common areas to be clean and properly furnished at the time of the visit.

OUTDOOR SPACE: The backyard does not have a covered patio area and both passageways were obstructed with a trashcan and baby gate respectively. There were no bodies of water on the premises. LPA observed a locked storage shed in the backyard. LPA observed 2 (two) latched self-closing side gates, however, 1 (one) gate was not self-latching. Administrator attempted to fix the side gate and was able to make it self-close, however, it does not latch. Administrator locked the gate which is a fire clearance hazard.

GARAGE: At 10:11AM, LPA toured the garage. The garage has a washer and dryer, locked cleaning supplies, an additional refrigerator and freezer, an emergency water supply and an additional pantry for extra food.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 05/15/2024.

RECORD REVIEW: LPA began record review at 10:40AM. LPA reviewed 6 (six) out of 6 (six) resident files and 4 (four) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. LPA observed 3 (three) resident files to be missing updated and current needs and service appraisal plans. Staff files were complete and had no missing documents.

Report Continued on LIC 809-C

INTERVIEWS: During today's visit, LPAs interviewed 2 (two) staff and 2 (two) residents.

During today's visit, LPA obtained a copy of the facility's liability insurance.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.