Routine inspection·July 12, 2021

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required/infection control inspection. LPA met with staff, Fredesvinda Farinas, Naty Domingo and Resurreccion 'Sion' Natividad, and informed the purpose of visit. LPA spoke over the phone with Marissa Rubio, licensee-administrator. Marissa can not come to the facility and authorized Resurreccion to be with LPA during inspection and receive this report. LPA toured the facility inside out with Resurreccion Natividad. LPA inspected the living and family rooms, dining area, bathrooms, kitchen, garage, side and back yards. Food supplies were observed sufficient for 2 days of perishables and 7 days of non-perishables. LPA observed COVID-19 signage by the dining area. Personal protective equipments (PPEs) were sufficient for 30 days. All staff were fit tested for N95 respirators. Facility has a copy of approved LIC808 Mitigation Plan on file. Hot water temperature in one of the bathrooms was tested. Fire extinguisher checked, observed fully charge; however tag showed serviced December 26, 2019; licensee stated fire extinguisher is scheduled to be serviced. Facility has working smoke and carbon monoxide detectors. The following documents to be submitted by July 26, 2021: 1. Copy of surety bond coverage 2. Copy of proof of $3M liability insurance coverage .....continued next page (809C) LPA observed the following: 1. Medication cabinet, cabinet where cleaning and laundry supplies were kept, and cabinet for knives were unlocked. 2. Medications in unlocked staff bedroom. 3. Trash cans without lids in bathrooms and residents' bedrooms. 4. No hand washing posters in bathrooms and kitchen 5. No visitor's poster in the entrance door 6. Although staff screened LPA's temperature, there's no central station for visitor's log, hand sanitizer and/or masks by the front door. 7. Hot water was measured at 103.5 degrees Fahrenheit. Deficiencies is cited from Title 22 California Code of Regulations (see 809Ds). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties. Deficiencies and plan and proof of correction were discussed with Marissa Rubio over the phone. Exit interview conducted with Resurreccion Natividad. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided at the conclusion of interview.