Facility Evaluation Report

An unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan on 8/30/24 at 10:00 am. Upon arrival LPA met with facility staff Iyan Medi, who granted access to the facility. LPA explained the reason for the visit. Shortly after the facility Administrator Jeffrey Savella arrived and helped with physical plant tour and provided staff/residents files.

During today's visit, LPA conducted a physical plant walk through, at approximately 10:40am, to ensure that

the facility is in compliance with rules and regulations under California Code of Regulations, Title 22.

Facility is licensed for capacity of six (6) residents, of which six (6) may be Non-Ambulatory and one (1) bedridden. The facility has hospice waiver for six (6) residents. LPA observed all required postings were on the wall. This is a single-story house with five (5) bedrooms, of which 4 bedrooms are designated for residents’ use. Bedroom #1 and Bedroom #2 are private. Bedroom #3 and Bedroom #4 are shared have their own bathroom. Bedroom #5 is designated for staff. LPA observed staff bedroom was free of hazards. Bedrooms are appropriately furnished and have appropriate lighting. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 10:55 to be 111°F. Extra towels and linens were readily available. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination. The facility has alarms on all exit doors, LPA observed alarms are operational. Centrally stored medications are locked in the cabinets located in the kitchen area. PRN medications have written orders from a physician. The facility serves residents with dementia and staff meets the needs of residents with dementia. Potentially dangerous items are kept inaccessible to residents with dementia. There is staff to meet Facility has 2 staff for AM shift and 1 awake caregiver for PM shift. No immediate health or safety concerns were observed.