Beginning at 11:03AM, the LPA, along with Administrator 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. The following was observed:

Hardwired combination smoke and carbon monoxide detectors were tested at 01:09PM and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 04/25/2024.

BEDROOMS: There are 4 (four) total bedrooms; 3 (three) are for private resident use and 1 (one) is designated for shared use. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. 2 (two) full bedrails were observed on Resident #1 (R1)'s bed and 1 (one) full bedrail was observed on Resident #2 (R2)'s bed. Neither R1 nor R2 are on hospice.

RESTROOMS: The LPA observed 2 (two) restrooms in the facility; 1 (one) is for shared use and 1 (one) is designated for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in both resident restrooms and measured within the required range.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed in the living room to be adequately screened and inaccessible to residents in care. Auditory exit alarms were functional at the time of the visit. Report Continued on LIC 809-C

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

A locked garage was observed adjacent to the kitchen and contained extra food, emergency food & water supply, storage, and laundry area.

RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records were reviewed. 2 (two) residents with a diagnosis of dementia did not have current annual medical assessments. The medical assessment for Resident #3 (R3) was dated 04/28/2023 and the medical assessment for Resident #4 (R4) was dated 08/15/2023. 5 (five) staff files reviewed were complete and contained all required documents.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly.

MEDICATION REVIEW: Medications for 2 (two) residents were observed. Both 2 (two) of 2 (two) residents' medications were observed to be maintained and administered in compliance with regulation. LPA provided Administrator with the Department's RCFE Medication Guide via email.

INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) residents and 2 (two) staff. No concerns were identified.

During today's visit, LPA obtained a copy of the facility's liability insurance.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or CA Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with Administrator. A copy of the report and appeal rights were provided.