Routine inspection·July 21, 2021

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required/infection control inspection. LPA met with staff, Leticia Iroy and Dioscoro Iroy, and informed the purpose of LPA's visit. LPA called and spoke with Juliana Taburaza, administrator. Juliana Taburaza authorized Leticia Iroy to be with LPA during inspection and receive this report. LPA toured the facility inside and out with Leticia Iroy. LPA inspected the living room, dining area, kitchen, resident rooms, bathrooms, side yard and backyard. Medications are centrally stored in a locked area that is inaccessible to residents and refilled every 30 days. LPA observed food supplies for 2 days of perishables and 7 days of non-perishables, LPA observed COVID-19 signage all throughout the facility. Facility has hand sanitizer, masks and gloves available for visitors located inside near visitor's entrance door. Facility has visitor's log. Personal protective equipments (PPEs) inspected. Facility has a copy of approved LIC808 Mitigation Plan on file. Hot water temperature in one of the bathrooms was tested and measured at 115.5 degrees Fahrenheit. Facility has working smoke and carbon monoxide detectors. Fire extinguishers checked, observed fully charge with tags showed serviced October 19, 2020. Administrator to submit the following updated documents by August 4, 2021: 1. Proof of $3M liability insurance coverage 2, LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan 4. Copy of surety bond coverage ......continued on 809C LPA observed the following: 1. Exit door in the kitchen with no auditory signal and front door signal not working. 2. When asked, staff (S1) didn't know about screening of visitors prior to allowing entry. This was discussed by LPA at 10:35 am over the phone with Juliana Taburaza. 3. Insufficient supplies of N95 respirators and disposable gowns. 4. No record of staff's N95 respirator fit testing. 5. Trash bins in the bathrooms without lids. Deficiency is cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of correction by plan of correction due date, and any repeat violations within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with Juliana Taburaza over the phone in the presence of Leticia Iroy. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Leticia Iroy.