KITCHEN: The LPA inspected the kitchen/food service area at 9:10 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps stored in a locked drawer inaccessible to residents in care. Cleaning supplies were also observed locked and inaccessible under the kitchen sink.

COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 9:21 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed to be in compliance and newly purchased on 01/4/2024. The LPA observed a closet in the hallway with extra towels and linens.

(Report Continued on LIC 809C...)

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There was one (1) gate that self-latches. No bodies of water were noted at the time of the visit.

BEDROOMS: There are four (4) resident bedrooms. Two (2) bedrooms are single occupancy, and two (2) bedrooms are double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are two (2) resident restrooms. The first restroom is located in the hallway and the second restroom is located in bedroom #3. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in both bathrooms and found in compliance as the both measured 110.6 degrees Fahrenheit.

RECORDS: Records review began at 9:31 a.m.; two (2) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms.

At 9:48 a.m., records review of Resident #1’s (R1’s) physician’s report dated 10/18/2023 revealed that R1’s ambulatory status is considered bedridden; however, facility is approved for bedridden in Room #4 and R1 is currently living in Room #3 which is approved for non-ambulatory only.

(Report Continued on LIC 809C...)

The last emergency disaster drill took place on 01/02/2024.

MEDICATIONS: Medications review began at approximately 11:15 a.m.; medications are centrally stored in a locked cabinet in the living room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. A $500 immediate civil penalty is assessed today. Failure to correct the deficiencies may result in additional civil penalties.

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