Peaceful Kingdom Home Care 2

Type of visit: Prelicensing

At approximately 10:56 AM on 03/10/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced prelicensing inspection to verify deficiencies have been corrected. LPA met with Licensee and disclosed the reason for the visit. Census: 3 residents Water temperature – On 03/08/2022, LPA measured water temperature to be below 105 degrees Fahrenheit. On 03/10/2022, LPA measured water temperature at 122.5 degrees Fahrenheit at approximately 11:15 AM. LPA returned at approximately 2:45 PM measured water temperature at 121 degrees Fahrenheit. LPA measured water temperature at approximately 3:45 PM to be 119.8 degrees Fahrenheit. All deficiencies found during the 03/08/2022 prelicensing inspection have been corrected. LPA conducted exit interview and issued a copy of the report.the state’s words, verbatim · CDSS document, Mar 10, 2022

Type of visit: Prelicensing

At approximately 1:06 PM on 03/08/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced prelicensing inspection. LPA met with Licensee and disclosed the reason for the visit. LPA toured the facility inside and out. Census: 3 This prelicensing inspection was conducted for a change of ownership with residents in care. The facility had an approved fire clearance for 6 bedridden residents. The facility had 5 bedrooms and 2 bathrooms. LPA observed functioning auditory alarms on all exits. LPA tested smoke detectors and carbon monoxide detector to be functional. A fire extinguisher hung near the kitchen. It was last inspected on 01/24/2022. All hazardous items and chemicals were stored and locked. LPA was screened for temperature and symptoms of COVID-19. Staff prompted LPA to record information in a visitor log. The facility had signs relating to COVID-19 hung throughout. All rooms, furniture, ceilings, and floors were clean, temperate, in good condition, and free from odors. LPA observed postings at the dining area for resident rights, resident councils, confidential complaints, and ombudsman contacts. LPA also observed a free house telephone at the front entrance. Bedrooms: Bedroom #2 was occupied by a bedridden resident. Bedroom #5 contained 2 residents, and one resident used oxygen. The bedroom had a “No smoking – Oxygen in use” sign posted on the door. Bedroom #3 was a staff bedroom. The bedroom was unlocked and contained no hazardous items. Bedroom #1 and Bedroom #4 were vacant. All bedrooms contained lamps, nightstands, adequate storage, and beds with sufficient sheets, blankets, and pillows. In the hallway, LPA observed two linen closets with adequate supplies of clean hand towels, bath towels, and bedsheets. The facility leaves the hallway light on at night to illuminate the path to the communal bathroom. Bathrooms: The facility had 2 bathrooms. One was a communal bathroom at the end of the hallway between Bedroom #1 and Bedroom #2. Another bathroom was private to Bedroom #5. All bathrooms contained fully stocked liquid soap, paper towels, trash cans with lids, non-skid material on the shower floors, and handwashing instruction signs. Toilets did not have grab bars, but residents in care used commodes with grab bars. The facility also has extra assistive toileting devices for new residents. Kitchen: LPA observed adequate supplies of perishable and non-perishable food. LPA also observed a weekly menu. All surfaces were sanitary and tidy. LPA saw a first aid kit with an approved manual, dressings, bandages, scissors, tweezers, and thermometer. LPA observed water temperature in the communal bathroom to be 103.9 degrees Fahrenheit. LPA observed temperature in the refrigerator and freezer to be 30.1 degrees Fahrenheit and -16.1 degrees Fahrenheit, respectively. Outdoor: LPA observed all exit paths to be free from obstructions and unlocked. Outdoor areas were well maintained. LPA reviewed Component III with Licensee. LPA issued report and conducted exit interview.the state’s words, verbatim · CDSS document, Mar 8, 2022

Type of visit: Case Management - Other

At 1:50 PM on 02/08/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced case management visit. LPA met with staff and disclosed the reason for the visit. Census: 1 Staff took LPA temperature and had LPA record symptom information and temperature in a visitor log. Staff informed LPA a resident was taken to the hospital last night. LPA visited with the resident in care who reported they are doing well. LPA observed new fire door in resident’s bathroom. LPA tested all auditory alarms in the facility. 4 out of 4 alarms functioned properly. All indoor spaces were clean and tidy. LPA conducted exit interview and issued report.the state’s words, verbatim · CDSS document, Feb 8, 2022

Type of visit: Case Management - Other

At approximately 1:55 PM on 01/05/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted a Case Management visit. LPA met with staff and disclosed the reason for the visit. Census: 2 LPA was screened for COVID-19 symptoms at the front entry door. LPA documented temperature on forms provided. LPA heard Dementia buzzer as the front door opened. LPA conducted a physical plant tour at approximately 2:00 PM. LPA met with both residents. At approximately 2:14 PM, LPA and staff tested 8 smoke detectors and 1 Carbon Monoxide detector. 8 out of 8 smoke detectors and the carbon monoxide detector worked when tested. LPA still heard the smoke detector in the living room beep once every 30 seconds. Staff noted they replaced all batteries recently, and Licensee plans to call electrician to fix the one malfunctioning smoke detector. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Jan 5, 2022

Type of visit: Case Management - Other

At approximately 11:32 AM, Licensing Program Analyst (LPA) Nicholas Reed arrived to Peaceful Kingdom 2 for a Case Management visit. LPA met with Administrator and discussed the purpose of the visit. Census was 3 residents. LPA was screened for temperature and COVID symptoms at the front, Staff took LPA’s temperature and instructed LPA to sign Visitor Log and a COVID symptom sheet. At approximately 11:42 AM, LPA and Administrator addressed the facility’s fire safety. LPA heard 3 fire alarms beeping throughout the facility. Licensee reported the beeping in a phone conversation on 12/21/21. Licensee replaced all batteries in fire alarms, yet beeping persists. In a tour of the kitchen, Administrator showed LPA a fire extinguisher which was inspected in March 2021. LPA approved of the extinguisher and discussed Fire Safety policies with Administrator. LPA conducted exit interview, issued technical assistance, and emailed report to Administrator.the state’s words, verbatim · CDSS document, Dec 22, 2021

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: Change in Ownership Capacity: 6 Census (if any clients in care): 5 COMP II Participants: Starr Craver, Applicant Jose Hernandez, Applicant Maria Victoria Paredes, Administrator Interview Method: Telephone interview On December 17, 2021 at 1:00 PM, Applicants and Administrator participated in COMP II. Identification of the Applicants and Administrator was verified through interview questions based on photo ID (CA Driver License) and other identifying personal information. During COMP II, Applicants and Administrator confirmed the understanding of the California Code Title 22 Regulations. During COMP II, CAB analyst confirmed Applicants and Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readiness Exit interview conducted with Applicants and Administrator. Analyst will send report via PDF email and informed, Applicants and Administrator to sign and return back to CCL.the state’s words, verbatim · CDSS document, Dec 17, 2021