At 9:10 AM, LPA began the tour of the physical plant in the presence of staff member Helena. The facility was observed to be clean, in good repair, and maintained at a comfortable temperature with adequate lighting. During the tour three staff members were seen present in the facility. The residents were away at the day programs at Rincon Mission Bay in San Jose and Main Street Mission Bay in Milpitas. The facility sketch includes 4 resident bedrooms, 2 resident bathrooms, a living room, a kitchen with dining, a laundry room, and 4 exit doors for access to the exterior area of the facility. No accessible bodies of water or fire safety / tripping hazards were observed.

At 9:18 AM, LPA inspected all four residents’ rooms and observed them to be clean with sufficient furniture and operational light fixtures. Two rooms are private and 2 rooms are shared. The bathrooms were observed clean and contained non-skid mats, grab bars, trash cans, liquid soap, and paper towels. The bathroom #1 faucet hot water temperature was measured at 108.3°F.

At 9:28 AM, LPA observed an office room next to the living room, which is not included in the facility sketch. According to the Administrator, this office room has been there in the facility since 2007. LPA asked the Administrator to email updated facility sketch to the CCLD.

At 9:36 AM, LPA inspected the kitchen and observed it to be clean. Toxins, cleaning supplies, and sharp objects were stored/locked properly and inaccessible to the residents. The facility had an adequate stock of food items, including 7 days of non-perishables and 2 days of perishables, with no expired food items observed. LPA observed 3 Ring cameras with Audio recording in Dining/Living, Kitchen and office, for which they have obtained consents from the residents RPs.

At 9:54 AM, LPA inspected the backyard area and noticed 1 garage and 1 storage shed. The latching lock on gates in the backyard were working. No obstructions and tripping hazards were observed. Storage Shed was locked and contained cleaning supplies and detergents.

At 10:08 AM, LPA inspected the garage and observed 2 freezers, 1 refrigerator and pantry cabinets with additional food supplies. Extra toiletries, diapers and other supplies were stored in separate cabinets.

At 10:19 AM, LPA inspected the fire extinguishers, which were observed to be fully charged and last serviced on September 2024. The smoke and carbon monoxide detectors were tested and observed to be operational.

At 10:23 AM, LPA reviewed five resident and five staff records. All were observed to be complete.

At 10:46 AM, LPA audited the Medication administration records (MARs) and observed them to be accurate. Resident medications were securely stored in a locked cabinet in the kitchen. No expired medications were observed.

At 10:58 AM, LPA inspected the First Aid kit and observed it to contain required supplies. Emergency drills are conducted monthly with the last drill documented on 09/10/2024.

The following updated forms are requested to be submitted to CCLD by 10/09/2024:

1) LIC 500: Personnel Report 2) LIC 308: Designation of Facility Responsibility 3) Surety Bond 4) Administrator Certificate 5)Liability Insurance 6) LIC 999: Facility Sketch Floor Plan

At 11:17 AM, LPA asked the Administrator to send application for Change in Administrator to the department.

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Naward Hernandez Smith, Administrator and a copy of this report was left at the facility.