Routine inspection·November 9, 2021

Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with John Ronald Olivarez, licensee. LPA also met with Celeste Olivarez, facility staff/consultant. LPA later met with Sarah Balingit, administrator. LPA informed the purpose of visit. Facility has completed COVID-19 mitigation plan and submitted to Community Care Licensing (CCL). LPA observed a hand sanitizer and a box of disposable gloves located close to the entrance door and visitor's log close to the office. Staff were observed wearing mask. Supplies of centrally stored PPEs inspected. LPA inspected the facility inside out with Sarah. LPA randomly selected 5 residents and staff rooms for inspection. LPA also inspected 3 common bathrooms, staff bathroom, dining area, kitchen, front and backyard. There were at least 7 days of nonperishable and 2 days of perishable food supplies.. Fire extinguishers were observed fully charge and tags showed serviced August 2, 2021. Hot water temperature in the 1 of the bathroom sinks was tested and measured at 118.4 degrees Fahrenheit. LPA observed the following: 1. Three bedrooms inside the staff room. Each of these rooms have door and permanent walls. 2. No COVID-19 signages through out the facility. No hand washing posters in the kitchen and bathroom sinks. No 6 feet physical distancing signs. 3. No visitor and no "Wear mask" posters on the entrance door. ....continued on 809C 4. Trash cans without lids in all 3 bathrooms and trash can's lid in the kitchen not "touch free". 5. Supplies of N95 respirators and surgical masks not sufficient for 30 days. No disposable gowns and face shields. 6. Staff were not fit tested for N95 respirators. Administrator to submit the following updated documents to CCL by November 23, 2021: 1. LIC500 Personnel Report 2. LIC610E Emergency Disaster Plan 3. Proof of $3M liability insurance LPA reminded that the annual fee is due by November 16, 2021. Deficiency is cited from Title 22 California Code of Regulations (see 809D). A $500.00 civil penalty is assessed for section 87202(a) and will continue for $100.00/day until corrected. Deficiency and plan and proof of correction were discussed with Sarah Balingit. Exit interview conducted. Appeal Rights, LIC421IM, LIC9098 Proof of Correction form and copy of this report provided.