Facility Evaluation Report

On March 22, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Chief Executive Officer (CEO), Diana Conti, Interim Director of Program, Patrice Clay, Interim Director, Marites De La Cruz and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. LPA toured four resident rooms, all of which were shared rooms. All resident rooms observed with all required furniture. LPA observed one staff/office room. Three full bathrooms were observed clean and odor-free; equipped with liquid soap, paper-towels, and non-skid mats. Hot water temperature throughout the facility measured between 113.7-116.4 degrees F. Extra linen was observed.

Living room and dining room was observed to be free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. Sharps, toxins and medications were locked and inaccessible to residents. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of October 2023. LPA toured the kitchen and observed 2 days for perishables and 7 days non-perishables. Emergency drills are logged and done every every month.

LPA reviewed 5 client records and 5 staff records. During record review, LPA observed 3/5 client files with no signed admission agreement, 3/5 files did not have physician's reports, 5/5 did not have functional capabilities assessment. Based on staff records observed, 3/5 files reviewed did not have health screenings. During the visit, LPA discovered that 7 staff members were not associated to the facility. During the visit, Interim Director of Program provided LPA with required documents to associate individuals to the facility.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with the CEO, Interim Director of Program and Interim Director and a copy is provided with appeal rights.