Pre-licensing visit·October 14, 2022

Licensing Program Analyst (LPA) Delmundo conducted pre-licensing inspection. License application is for six (6) total capacity, all non-ambulatory of which one maybe bedridden. Fire clearance was granted on July 12, 2022. Application is for change in ownership and facility is currently in operation. LPA met with Elaine Yalung, applicant-administrator. LPA toured the facility inside out with applicant. There is no body of water. LPA inspected the living room, dining area, family room, kitchen, bedrooms, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed sufficient good for seven days of non-perishables and 2 days of perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinets were knives and closet were medications are centrally stored were observed locked. A central screening table for staff and visitors was observed set-up by entrance door. Facility has central storage for PPEs. Bathrooms/showers were observed equipped with grab bars and non-skid mats. Complaint poster, Ombudsman and Personal Rights posters, Theft and Loss Policy, Rights to Resident Council and Rights to Family Council were observed posted in the prominent place. All exit doors were observed with auditory signals. Fire extinguisher checked and observed fully charge with tag showed serviced April 6. 2022. Carbon monoxide and smoke detectors operational. First aid kit inspected. Facility has flash lights for emergency lighting. Hot water temperature in one of the common bathrooms was tested and measured at 106.3 degrees Fahrenheit. Facility has land line phone which LPA tested and observed operational. .....continued on 809C (page 2) LPA observed the following: 1. No 'Wear Mask' poster - posted while LPA was at the facility. 2. Side fence in disrepair. 3. PPEs not sufficient for 30 days for 5 staff. LPA verified and according to applicant, the new facility Infection Control Plan was submitted to Central Application Bureau (CAB) analyst, but without Monkeypox Infection Control Plan addendum. LPA also verified and learned that staff are not fit tested for N95 respirators. LPA reminded applicant of the following upon granting of license: 1. Obtain $3M liability insurance for this facility, and submit copy of proof to Community Care Licensing Oakland Regional Office. 2. Updating of residents and staff file to reflect facility name and number. LPA will inform CAB analyst upon receipt of proof of corrections. Final review of application and license to be granted by CAB analyst. Exit interview conducted and copy of this report provided to Elaine Yalung