Routine inspection·June 22, 2021

Licensing Program Analyst LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Warlita Agmata-Rivac. LPA called and spoke with Ksai Liang, licensee-administrator. LPA informed both Warlita and Ksai the purpose of LPA's visit. LPA asked and Ksai, authorized Warlita to be with LPA during inspection. LPA also met with other staff, Merlyn Agustina Lie. Ksai arrived after about 3 hours. LPA toured the facility inside and out with Warlita. LPA inspected the resident rooms, bathrooms, kitchen, living room, dining area, side and backyards. Medications are centrally stored in a locked area that is inaccessible to residents and refilled every 30 days. Perishable and non-perishable food supplies were observed sufficient. Fire extinguisher checked, observed fully charge, and tag showed serviced July 17, 2020. LPA observed the following: 1. Merlyn is not fingerprint cleared. Documents obtained from Warlita showed Merlyn started working June 2, 2021 which LPA confirmed with Warlita and Merlyn. 2. Personal protective equipments (PPEs) such as disposable gowns and N95 mask not sufficient for 30 days. 3. There's no hand washing poster in the kitchen, and droplet pre-cautions and cough etiquette posters anywhere in prominent place in the facility. There's also no updated visitor's poster in the front door. 4. Trash bins in the all 3 bathrooms with no lids. 5. Visitors' temperature not checked. .....continued next page (809C) The following updated documents need to be submitted by July 6, 2021: 1. LIC500 Personnel Report 2. LIC610E Emergency Disaster Plan 3. Proof of $3M liability insurance coverage Deficiencies are cited from Title 22 California Code of Regulations (see 809Ds). A $500.00 civil penalty is assessed on this day. Failure to submit proof of corrections by plan of correction due dates and any repeat violations within 12 month period may result additional civil penalties. Deficiencies and plan and proof of correction were discussed with Ksai Liang. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.