Routine inspection·December 9, 2021

Licensing Program Analyst (LPA) Delmundo conducted an unannounced infection control annual inspection. LPA met with Maria Carmela 'Marla' Rocero, administrator, and informed the purpose of visit. LPA also met with other staff, Rebecca Go and Noel Rocero. Facility has an approved LIC808 COVID-19 Mitigation Plan. LPA inspected the facility inside and out. LPA observed screening station located near the front entrance with visitor's log, hand sanitizer and no touch temperature probe. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and visitors. Medications are centrally stored in the a locked cabinet. Centrally stored PPEs inspected. There were at least 7 days of nonperishable and 2 days of perishable food supplies. Fire extinguisher was observed fully charge and tag showed serviced December 3, 2021. Smoke and carbon monoxide detectors were operational. First aid kit inspected and observed complete with manual. LPA observed the following: 1. Storage for cleaning supplies in the backyard without lock. LPA observed bleach, floor cleaner, carpet spot cleaner inside the storage. 2. Gardening tools such as rake and shears in the side yard. 3. Worn out wheelchairs, broken pipes, floor cleaner, 2 pails of paint in the backyard. 4. Dowel at the bottom of sliding door in the residents' shared bedroom. .....continued on 809C 4. No visitor's poster and COVID-19 signages at the entrance door. 5. No COVID-19 signages inside the facility except in the common bathroom. 6. Trash bins in the bathrooms without lids. 6. Disposable gowns, N95 respirators, surgical masks not sufficient for 30 days for 3 staff. LPA verified and Marla Rocero stated the following: 1. Staff are not fit tested for N95 respirator. 2. Residents' temperature are not routinely checked. LPA requested for copies of the following updated documents to be submitted by December 23, 2021: 1. LIC500 Personnel Report 2. LIC308 Designation of Facility Responsibility 3. LIC610E Emergency Disaster Plan 4. Proof of $3M liability insurance coverage Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with Marla Rocero, Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.