Community Care Licensing
Document Has Been Signed on 08/14/2025 06:21 PM - It Cannot Be Edited
The LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.
COMMON AREAS: This includes the living room, dining room and open office area. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 12:07 p.m., hardwire combination of smoke / carbon monoxide detectors were tested and operational at the time of the visit. The fire extinguisher was observed expired dated 09/22/2023 which poses / posed an immediate health and safety risk to persons in care. LPA informed Administrator the importance and requirement of having an active fire extinguisher. The Administrator agreed to purchase new fire extinguisher today 08/14/2025. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill is unknown. LPA informed Administrator the importance and requirement of drills conducted quarterly. The Administrator agreed to conduct a drill this week. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises.
Report Continued on LIC 809-C PAGE 2...
BEDROOMS: There are six (6) total bedrooms in the facility; four (4) bedrooms are designated as private, single occupancy, resident rooms and two (2) staff rooms. The staff rooms are kept locked at all times and observed to be occupied by staff. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.
RESTROOMS: The facility contains three (3) total restrooms. Administrator indicated 1 (one) is for resident use and 2 (two) are for staff use. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in the resident restroom at 10:58 a.m. and measured 112.5 degrees Fahrenheit, within the required range.
KITCHEN: The LPA inspected the kitchen/food service area at 11:03 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 118.6 degrees Fahrenheit at 11:07 a.m. Cleaning supplies and other chemicals are kept in the laundry room locked and inaccessible to residents in care.
LAUNDRY ROOM: LPA observed the locked laundry room adjacent to the resident restroom. Laundry room has a washer and dryer and locked cleaning supplies.
BACKYARD: The entire property is fenced. The backyard has a covered patio area with shade, patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. The pathway used as an emergency exit was free of obstructions at the time of the visit. LPA observed a swimming pool that was gated and locked. The garage was locked and attached to the house.
Report Continued on LIC 809-C PAGE 3...
RECORDS: Record review began at approx. 11:10 a.m.
Resident Records :were reviewed beginning at 11:15 a.m. two (2) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Resident #1 had an incomplete appraisal and missing LIC 621, updated physician report, needs and service plan. During the visit LPA observed R1 to be on a Gastrostomy tube (G-tube). During record review LPA did not see any documentation of R1 having any documentation on the Prohibited Health Condition which poses an immediate health and safety risk to persons in care. LPA was informed by the Administrator that R1 will be placed on Hospice however it is still being discussed by the family. Resident #2 was missing paperwork however it was cited in a Case Management visit conducted on 08/07/2025.
Personnel Records: were reviewed beginning at 11:50 a.m. two (2) Personnel files including the Administrator’s file were attempted to review including but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were missing. Administrator stated they did not have any of the staff files as they are currently reviewing them at an off site location which poses a potential health, safety or personal rights risk to persons in care. LPA informed Administrator the importance of having all files available. Administrator agreed to have files on site after self audit was completed.
INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facilities emergency disaster plan. The facilities policies and procedures, as they pertain to emergency planning, are satisfactory. At the time of the visit the infection control plan was not available which poses a potential health, safety or personal rights risk to persons in care. LPA informed Administrator the importance of having all files and records available. Administrator agreed to email LPA the plan once completed.
MEDICATIONS: Medication review began at approximately 12:05 p.m. Medications are centrally stored and locked in a cabinet in the kitchen adjacent to the dining room. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review. Report Continued on LIC 809-C PAGE 4...
DOCUMENTS: Documents obtained during the visit include: LPA did not collect any documents as Administrator stated they did not have their paperwork on site. LPA requested Administrator email their LIC 500 facility roster and LIC 9020A Resident roster and copy of the Limited Liability insurance.
INTERVIEWS: Starting at 12:30 p.m. Two (2) staff and one (1) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. During the interview, R1 was unable to effectively communicate with the LPA. When prompted with questions, R1 did not provide verbal responses but instead made grunting sounds that could not be interpreted.
The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.