Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to six elderly residents, up to six may be non-ambulatory. Facility does not have a clearance for bedridden, delayed egress, and locked exterior/interior. Facility has a hospice waiver for four residents.

Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident units, resident bathrooms, dining room and outdoor areas.

LPA inspected 4 resident bedrooms and 2 bathrooms. Bathrooms are equipped with non-skid flooring and grab bars. Faucet, toilet and shower are in working condition. Hot water temperature was 112 degrees Fahrenheit in one of the bathrooms. During inspection of the bathrooms, LPAs observed resident medications, such as eye drops, powder, and nostril spray, were accessible in the bathroom. Also, LPA observed Lysol spray under the bathroom sink. Personal hygiene items were also accessible.

Room temperature was maintained at 76 degrees Fahrenheit throughout this visit. There is a fire door leading to two of the residents’ bedrooms. Per fire safety, advisory was provided to ensure the fire door is closed at all times.

{1 OF 3}

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

In one of the cabinets leading to the laundry area, LPAs observed Roach and Ant Spray and other chemicals inside one of the cabinets that were accessible to residents. Also, LPAs observed one cockroach in this cabinet. Per AD, they utilize pest control. Per review of their pest control contract, they receive pest control services at least quarterly or as needed to include cockroaches.

Outdoor area was inspected. Walkways were observed to be unobstructed. Fence and gate were in good repair at this time. No bodies of water were observed at this time. There is a shaded area for outdoor activities. LPA observed outdoor furniture. Shut-off valves were located. Advisory was provided to ensure all staff know the location of each of the shut-off valves and know how to operate each one in case of emergency. LPAs observed paint containers that were accessible to residents. LPAs observed gardening tool (shovel) accessible to residents.

Record Reviews: Review of 3 of 5 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. Per review, all three residents were assessed to be at risk if they have direct access to personal/hygiene items. Advisory provided to ensure they maintain hospice care plan for all residents receiving hospice care.

Medication review was conducted for 1 resident, including review of resident’s medication, PRN authorization letter, prescription records, Centrally Stored Medication Records, and Medication Administration Records. Advisory was provided to ensure they do not pre pour medications. Medication Guide was provided to AD to review.

Review of 2 staff files included but not limited to background clearance, first aid/CPR certification, and training.

{2 OF 3}

Interviews: One staff member and one resident in care were interviewed.

Documents Requested: LPA requested a copy of updated Liability Insurance, LIC500, and LIC308.

Per the California Code of Regulations, Title 22, Division 6, deficiencies were cited.

Exit interview was conducted with AD. A copy of the report was provided upon exit.

{3 OF 3}