Routine inspection·July 13, 2021

Licensing Program Analyst LPA) Delmundo arrived unannounced to conduct an annual required/infection control inspection. LPA met with Justino Balintona, licensee-administrator, and informed the purpose of LPA's visit. LPA also met with staff, Warlita Romero and Corazon Mariano. LPA toured the facility inside and out with Justino Balintona. 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, 60 and 90 days. Perishable and non-perishable food supplies were observed sufficient. LPA observed COVID-19 signage all throughout the facility. Staff checked LPA's temperature upon entry. Facility has hand sanitizer, masks and gloves available for visitors located inside by the entrance door. Facility has visitor's log. Step-on trash bins with lids observed. 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 105 degrees Fahrenheit. Facility has working smoke and carbon monoxide detectors. Fire extinguisher checked, observed fully charge but no service tag. According to Justino, the unit was purchased March this year. LPA obtained copies of the following: 1. Copy of proof of $3M liability insurance coverage 2. Updated facility sketch 3. LIC9054 Local Fire Inspection Authority Information .....continued next page (809C) LPA observed the following: 1. Visitor's log has no columns to record temperature and contact information. 2. No supplies of N95 respirators and disposable gowns. 3. Licensee unable to locate their supply of face shields. 4. Staff not fit tested for N95 respirators. 5. Bed frames and old mattress in the side yard. 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 Justino Balintona. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.