Beginning at 10:15AM, the LPAs, along with 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 extinguishers are fully charged and recently serviced on 05/16/2024. Smoke and carbon monoxide detectors were tested at 11:11AM and all were functional at the time of the visit.

KITCHEN: Kitchen was observed to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of 7 (seven) days non-perishable and 2 (two) days perishable food. Knives were observed to be locked in a cabinet above the stove. The stove did not have knobs and was free of safety and hazard concerns. Cleaning supplies are located in a locked under-sink cabinet. At 10:18AM, LPAs began checking the food supply in the kitchen pantry. A total of 11 (eleven) cans were found to be expired and/or dented, making them unsafe for consumption. The LPAs observed the temperature of the freezer to be set at 8 degrees Fahrenheit, but food items in the freezer were thawed and room temperature. Staff 1 (S1) disposed of all expired/dented cans and the full contents of the freezer. Facility does not have an adequate emergency water supply.

BEDROOMS: There are 7 (seven) total bedrooms in the facility; 6 (six) are designated as private resident rooms and 1 (one) is utilized as a staff room. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. At 10:54AM, staff room was observed to be unlocked and contained unsecured cleaning supplies and medications, making them accessible to residents.

Report Continued on LIC 809-C

COMMON AREAS: This includes the living room and dining room areas. LPAs observed common area to be clean and properly furnished at the time of the visit. The living room has a properly screened fireplace. Exit doors contain alarms and all but the kitchen sliding door were functional at the time of the visit.

GARAGE Washer and dryer were observed to be in the locked garage. Garage was designated as an additional living quarters for staff use but was not utilized at the time of the visit.

OUTDOOR SPACE: The backyard and front yard have sitting areas with patio furniture including tables and chairs for resident use. The passageway on the east side of the facility was obstructed with a hospice bed. S1 notified LPAs that it was left out to be picked up by the hospice provider. There were no bodies of water on the premises. An outdoor shed was observed to be locked. The passageways on both sides of the house contain railings but were observed to be loose at the time of the visit.

EMERGENCY DISASTER PLANNING: During today’s visit, the LPAs attempted to review the emergency disaster plan. The facility’s policies and procedures as it pertains to emergency disasters are not updated annually and disaster drills are not conducted quarterly as required.

RECORD REVIEW: LPAs began record review at 11:23 AM. Staff and resident records were reviewed 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. 4 (four) staff files observed were missing documents. 4 (four) of 4 (four) resident files were observed to be missing required documents.

MEDICATION REVIEW: Medications for 2 (two) residents were observed. At 12:26PM, LPAs observed writing on medication labels by facility staff. Facility did not have PRN authorization letters and guidelines for all PRN medications observed. Report Continued on LIC 809-C

During today's visit, LPAs were not able to obtain 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-Ds). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.