Facility Evaluation Report

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a follow up case management inspection related to the fire clearance for non-ambulatory residents. LPA met with Rowena Tirasol, caregiver, and Rosana Mead, Administrator, and explained purpose of the inspection. LPA observed (1) resident to be enjoying television in the common area and a second resident to be sitting on the front porch. LPA observed (5) residents present and a hospice nurse also present with one resident.

LPA stated she spoke with local fire inspector today who confirmed an inspection was made on 5/30/23 and room #1, in front, can only be approved for a non-ambulatory resident if an exit door is installed in the room as a primary exit. Fire inspector explained that the front door cannot be considered a primary exit.

LPA and Administrator toured the facility and observed a glass sliding exit door in rooms #4, 5 and 6 and an exit door from Room #3. License is currently approved for (5) non-ambulatory residents, (1) of whom can be bedridden. LPA reached out to fire inspector during today's inspection to confirm if room #3 is approved for (2) non-ambulatory residents.

The facility was issued a citation on 5/10/23 for a violation of the fire clearance due to resident (R1) who is non-ambulatory residing in room #1. Resident did not agree to move to another room by the POC date of 5/12/23, so a second citation is issued today. Resident agrees now that she cannot stay in a room that is not approved for a non-ambulatory resident and agrees to move to another room if approved for a second resident. Administrator to issue a 30-day eviction today should another room not be available for R1 to move into.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency is issued on the 809D page.

Exit interview. Copy of report and appeal rights provided to Administrator.