Facility Evaluation Report

On 01/17/2024, Licensing Program Analysts (LPAs) Stevenson and Felias arrived at 9:45am to conduct an unannounced Annual Required – 1 yr. Inspection for this facility and was greeted by Lead Staff, Agnes Ortiz and Administrator, Nina German. Licensee Jethro Nicholas arrived briefly and then had to leave. LPAs reviewed current Guardian staff roster and found all staff to be background cleared and associated to facility.

At approximately 10:15am, an inspection of the facility was done. Facility was found to be warm, clean with good lighting and without odors. Facility has a current census of 4 with one out of the community in skilled nursing,two attending day program, and one present during visit. Client bedrooms, common areas, kitchen & food storage areas were inspected. Food stored in the kitchen refrigerator, pantry and locked cabinets in the garage were stored properly as per regulations on this day at the time of the visit. Emergency food and water are stored in garage. Facility replenishes fresh food supply on a weekly basis. Fire Extinguisher was found to be last charged on 02/2024. Smoke and carbon monoxide detectors were found throughout the facility, tested and found to be in working order. Water at faucets were tested and found to be between 105 and 120F per Title 22 Regulations. During walkthrough, LPAs found a shelf organizer located in the facility locked staff room. LPAs observed that the organizer was blocking the room's sliding door that accessed the backyard patio. Facility staff immediately moved organizer to another part of the room. Review of facility sketch indicated that the staff room sliding door is not one of the identified emergency fire exits. LPAs discussed the importance of ensuring that all exits are not obstructed (technical advisory issued, LIC9102, regulation 80087(c)). Facility shed located in backyard had additional storage of PPE, paper towels and incontinence supplies. Medications are stored in a designated lockbox containers located in the kitchen area and found to be secured. A spot medication count was conducted for clients and found to be in order. Knifes, cleaning supplies and other items that could be potentially dangerous if accessible to clients were all secured and inaccessible.