Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/14/23 at 12:00PM. LPA met with Edmund Picardo, Caregiver who contacted the Administrator Kersten Ancheta regarding todays visit. Kelly Ancheta called facility to state she will arrive to assist with todays visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which wheelchair bound residents are allowed in room 4.

The Administrator Certificate for Kelly Ancheta was observed expired 5/18/23. LPA observed documentation of payment and hours for renewal dated 10/10/23 that has been submitted to Community Care Licensing (CCL). The late submission was cited on 10/9/23 at another facility for this Administrator which has been cleared. LPA observed P&I monies for Resident #1 (R1) which has been counted and documented properly and not commingled during this visit. Upon arrival 3 residents were out in the community with staff. On arrival back to the facility the residents had lunch. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 110.3*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), pull alarm system, smoke and carbon monoxide detectors in the facility.

Last emergency drill was conducted on 5/2/23. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 1 staff files and 2 resident files and conducted interviews during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:

Any addendums for the Infection Control Plan, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Affidavit Regarding Client/Resident Cash Resources (LIC400), Surety Bond (LIC402), Control of Property, Emergency Disaster Plan (LIC610D) .

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. An exit interview was conducted, a copy of the report was given.