At 11:40AM, the LPA, along with Administrator, conducted a tour of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Facility fire extinguisher was fully charged and recently purchased on 09/22/2023. All hardwired smoke alarms were tested at 01:57PM and carbon monoxide detectors were tested at 02:10PM and all functioned properly. The LPA observed all required postings throughout the facility.

Bathrooms: The facility contains 3 (three) bathrooms. Administrator indicated 1 (one) is for resident use and 2 (two) are for staff use. LPA observed the resident bathroom, which was properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats. The hot water was measured in the shared bathroom during the physical plant tour. Hot water measured at 116.0 degrees Fahrenheit, which is within the required range.

Bedrooms: The facility contains 6 (six) total bedrooms; 4 (four) are designated for resident use and 2 (two) are designated for staff use. The resident bedrooms were properly furnished and sufficient lighting. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Staff rooms were observed to be locked. Resident #1 (R1) was observed to have full bedrails. Administrator indicated that R1 had been on hospice and staff stated they had requested half rails for R1 from the vendor, but had yet to receive them.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked cabinet. Report continued on LIC 809-C

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture and a swimming pool that was gated and locked. The garage was locked and attached to the house.

Record Review: Beginning at 11:53AM, LPA reviewed staff and resident files. The LPA reviewed two (2) out of two (2) Resident Files for items including but not limited to: physician's reports, needs and service appraisal, personal rights. The LPA reviewed two (2) out of two (2) staff files for items including but not limited to: staff training, health screening, TB test results. All files reviewed contained all documents.

Emergency Disaster Plan/Infection Control Plan: During today's visit, LPA reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually as required. The LPA inquired about the facility's infection control plan. The facility does have a COVID Mitigation Plan and is following basic infection control practices, however did not have a written Infection Control Plan. LPA provided Administrator with the LIC 9282 form during the visit.

Medications: At 01:35PM, a medication review was initiated. Medications are centrally stored and locked in a cabinet in the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Interviews: Throughout today's visit, LPA interviewed 2 (two) staff and attempted to interview 2 (two) residents. During Administrator interview, it was identified that the Licensee corporation is suspended. Administrator agreed to contact the suspending agency and keep LPA updated with an action plan to get back into good standing.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted with Administrator. A copy of the report and appeal rights were provided.