Facility Evaluation Report

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Administrator, Virginia Jimenez, Continual Administrator's Certification expires 02/09/2028 There are currently 4 residents who reside at this home and there is 1 resident on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, office and outdoor areas. . There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 112 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

The facility did not notify Licensing of Resident 1's Hospice initiation. Resident 1's hospice care plan was not in hospice binder (staff did provide copy before end of visit.) Staff 1 needs TB test along with health Screening. Facility window screens are not in good repair, main hallway resident bathroom faucet closest to the window has low water pressure, bathroom vanity door knobs are lose, multiple facility vents appeared to be dusty/dirty.. Resident 2 does not have required furnishings (lamp.) Facility did not have required / updated resident roster. Resident 1's medications are not documented accurately on the Centrally stored medication record.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator, Virginia Jimenez, and copy of report left at facility