9 West Sidlee

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Sandra Urena conducted an unannounced required annual inspection visit. The LPA was greeted by staff, and the LPA explained the reason for the visit. The Administrator Mervin Galvez arrived shortly thereafter. The LPA and the administrator began the physical plant tour to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed one (1) designated drawer in the kitchen where knives are locked and inaccessible to residents. Medications were observed locked in a cabinet adjacent to the kitchen. BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated client rooms and one staff room. There was a linen closet in the hallway with extra towels and linens. RESTROOMS: Restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. Three (3) common and one (1) private bathrooms’ water hot water was measured and were in compliance measuring between 105- and 120-degrees Fahrenheit. .Continued on LIC 809C… COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 70 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher was fully charged and were last serviced on 06/12/2023. The LPA observed required postings throughout the common space. The washer and dryer are adjacent to the kitchen area. All laundry materials are located in a locked cabinet and inaccessible to residents OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. The garage is attached to the house and has a door by the front yard. The garage door was locked at the time of the inspection. RECORDS: Records review began at 11:30 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 12:15 p.m.; medications are centrally stored and locked in a cabinet adjacent to the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Fire drill - Liability Insurance No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 28, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced visit to 9 West Sidlee LLC to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 9:30 a.m. This will be the first Annual from their Pre-Licensing visit on 9/28/2021. The LPA was greeted and screened at the door by Administrator, Raymund Cesar and the reason for the visit was explained. Entrance interview. At 9:40 a.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed one (1) designated drawer in the kitchen where knives and sharps are locked and inaccessible to residents. Medications were observed locked in a cabinet adjacent to the kitchen. BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting. Auditory alarms were tested and functioning in all residents rooms at the time of visit. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. Between 9:42 a.m., and 9:47 a.m., three (3) resident bathrooms were measured for hot water and were in compliance measuring between 105- and 120-degrees Fahrenheit. …Report Continued on LIC 809C... …Report Continued from LIC 809... GARAGE AND GROUNDS: The garage is locked and inaccessible to residents. The LPA observed one (1) additional refrigerator stocked at the time of visit. Cleaning supplies and chemicals were observed in a locked cabinet by the laundry room. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit. COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed three (3) residents at the dining table at the time of visit. Fire extinguisher was observed and charged on 6/07/2022. During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19, and CDSS PINS. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff are fully vaccinated and boosted. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate. Exit interview conducted. No citations issued. Report was reviewed with Administrator and a copy was provided via email.the state’s words, verbatim · CDSS document, Oct 21, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an announced Pre-licensing visit to the above facility on 9/28/2021 at 8:30am. LPA met with Licensee Representative Gilliana Sherman as this is a change of ownership application from Thousand Oaks Home Care II #561704150 to 9 West Sidlee LLC #565850195. Licensee Representative completed Comp II on 09-10-2021 and Comp III on 09-24-2021. Entrance interview conducted. The applicant has obtained fire clearance for a total capacity of 1 (one) bedridden and 5 (five) non-ambulatory, for a total capacity of six (6) clients. Facility currently has six (6) non-ambulatory residents. Facility has seven (7) bedrooms and three and a half (3 1/2) bathrooms. All six (6) resident bedrooms are single occupancy. Seventh bedroom is for staff. LPA observed a central entry point by the entrance designated for temperature checks and check-in for staff, residents, and visitors. The smoke detectors and carbon monoxide detector were tested and were operational. LPA observed one (1) fire extinguisher in the kitchen to be fully charged and last serviced on 03-17-2021. LPA observed first aid kit and manual to be complete. The common living and dining areas are clean and properly furnished with seating, a table, and television for resident use. Facility currently has a working landline telephone. LPA observed ten (10) exit doors to have functioning auditory alarms when opened. All bedrooms, bathrooms, kitchen, and common areas windows have clean window coverings with screens and in good repair. Appliances in the kitchen were clean and all appeared functional. Facility has two (2) refrigerators, one in the kitchen and one in the garage. Both are fully stocked. LPA observed a sufficient supply of non-perishable and perishable foods. Facility has emergency food and water for residents and staff. LPA observed a laundry room with a locked cabinet where detergent, harsh chemicals, and cleaning supplies are stored. Medication is stored in a locked cabinet adjacent to the kitchen. LPA observed one designated drawer next to the refrigerator where knives and sharps are locked and inaccessible to residents. LPA reviewed facility records at 9:25 am. Staff and resident files are in order and are kept locked in a cabinet adjacent to the kitchen. Hallways were free of any obstruction. (...Continued on LIC 809C...) (...Continued from LIC 809...) There are six (6) resident bedrooms that were properly furnished. LPA observed all bedrooms to have a bed with clean linens, a nightstand, and adequate lighting. There are three (3) bathrooms for resident use. Bathrooms were measured for hot water, first bathroom measured at 106 degrees Fahrenheit, second bathroom measured at 105.8 degrees Fahrenheit, and third bathroom measured at 105.2 degrees Fahrenheit. Each bathroom was adequately equipped with toilet paper and paper towels, as well as grab bars and non-skid mats. LPA observed a covered patio area with patio furniture, a table, and chairs for resident use. LPA observed one (1) fence gate that self-latches for resident use in case of an emergency. No large bodies of water accessible to residents. LPA observed CDSS PINs, Emergency Exit Plan and necessary posters posted in the hallway easily accessible to residents. No firearms or ammunition will be stored in the facility at any time. Facility is in compliance with Title 22 Regulations at this time. The CAB Analyst will notify the applicant when the license has been approved. Exit interview conducted. A hard copy was provided via email.the state’s words, verbatim · CDSS document, Sep 28, 2021

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 Method: Telephone call with CAB Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by correctly answering identity verification questions. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicants have been advised to transmit signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Sep 10, 2021