Facility Evaluation Report

Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Licensee, Jose Pira, Continual Administrator's Certification expires 09/28/2027 . There are currently 5 residents who reside at this home and there is 1 resident on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested 100 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible.

Resident 1's Admission agreement does not have correct facility name or admission date listed. LPA observed food removed from original containers into unlabeled, containers with no date. Resident 2's ambulatory status is not listed on medical assessment (both ambulatory and non ambulatory boxes checked.) Resident 2 does not have required TB test. The facility does not have detailed plan to be self reliant for 72 hours in case of disaster. The facility does not have detailed plan on assistance with administering refrigerated diabetes medication in case of disaster. The facilities Infection control plan is not documented as updated annually. The facility is removing resident medications from original bubble pack container into weekly organizer. Resident 2's Centrally stored medication record is not accurate. Licensee moved facility residents from closed facility to current facility without providing residents required written notice.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Licensee, Jose Pira, and copy of report left at facility