Facility Evaluation Report

On February 9, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Mary Beth Sandoval and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. Facility operates on first and second level. The indoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. Outdoor and second floor exit route passageway was observed. Exit route passageways observed had chairs and a coffee table blocking the exit route.

There are seven shared client bedrooms, four common bathrooms, dining room, kitchen, activity room, laundry room, storage areas and offices. Client bedrooms were observed to have all required furniture. Bathrooms were clean and odor-free; equipped with soap and toilet paper. LPA checked the first aid kit and food supplies. 2 day perishables and 7 day non-perishable food were present. Sharps, toxins and medications were locked and inaccessible to clients in care. Water temperature throughout the facility measured between 106.8-137 degrees F. Men's bathroom on the second floor measured at 137 degrees F and staff bathroom on the first floor measured at 134.7 degrees F. Administrator printed out hot water caution signs and posted them in the men's and staff bathroom. Extra linen was observed to be present.

A comfortable temperature of 69 degrees F is maintained and lighting is sufficient for comfort. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of August 2023. Emergency drills are logged and done every month. LPA reviewed 5 client records and 5 staff records. Client records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.