Facility Evaluation Report

On 9/26/2023 at 8:55AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Sophia Tekle and explained the purpose of the visit. The facility’s fire clearance was approved for 4 bedridden clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Smoke detectors are interconnected with sprinklers system. Fire extinguishers were observed to be full. One week of non-perishable and 2-day perishable food supplies were sufficient. Hot water temperature was measured at 110.1 degrees F in the kitchen sink. All client bedrooms have automatic hoyer lifts and bathroom have hoyer lift installed. Cleaning supplies and toxins were locked and stored appropriately and inaccessible to clients. First Aid kit is complete. Last fire drill was conducted on 9/6/2023.

LPA reviewed 4 client and 3 staff files starting at 9:30AM. LPA reviewed client's P & I money with logs. LPA interviewed 2 staff and attempted interviews with 2 clients starting at 12:00PM. LPA reviewed a sample of client's medications starting at 11:34AM.

At 9:20AM, LPA observed unlocked of overflow medications and treatments in the kitchen cabinet. Administrator locked up the cabinet during inspection.

At 11:50AM, LPA observed centrally stored medication records was missing some medications that the clients was taking.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in Civil Penalties. Exit interview conducted. A copy of this report and appeal rights provided.