Routine inspection·June 15, 2022

On 6/15//2022 at 3:35PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Aurora Balancio, Administrator , and explained the purpose of the visit. Upon entry, LPA temperature was not checked. LPA observed screening station that contained hand sanitizer and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage, and back yard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing poster. Hot water temperature in the shared residents' bathroom was measured at 105.1 .degrees Fahrenheit. Fire extinguisher was serviced on 3/20/2021. During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed food, PPE and paper supplies are sufficient. The following forms are to be updated and submitted to CCLD by 6/22/2022 : -LIC9020 Register of facility Clients/Residents -LIC308 Designation of Administrative Responsibility Continued on LIC809C Continued from LIC809. -LIC610E Emergency Disaster Plan The following deficiencies were observed. -At 3:57PM, LPA observed a knife sitting on kitchen counter. -At 3:59PM, LPA observed a pile of dirty clothing sitting on a shower chair located in the shower stall in shared bathroom. -At 4:05PM, LPA observed a shovel, pruner, bags of clothing, 3 mattresses, 2 boxes of garbage, a wheelchair with clothing in seat, 2 ladders, bed railing, and a plastic 5-drawer bin in back yard. -At 4:50PM, LPA reviewed R1's file and did not observe an order for bed rails, incomplete physician's report, missing consent form, Identification and Emergency information, TB information, theft and loss, appraisal needs and services plan, and safeguard. -At 5:00PM, LPA reviewed R2's file. The file is missing consent form, theft and loss, appraisal needs and services plan 11/14/2018, physician's report 12/11/18, and safeguard. -At 5:10PM, LPA reviewed R3's file. The is missing Identification and emergency form, consent, physician's report 9/2018, and appraisal needs and services 9/26/18. -At 5:15PM, LPA reviewed R4's file physician's report 10/20/16 and appraisal needs and services 10/1/16. -At 5:20PM, LPA reviewed R5's file physician's report 10/13/2016 and appraisal needs and services 10/1/2016. Continued on LIC809C. Continued from LIC809C. -At 5:25PM, LPA reviewed R6's file appraisal needs and services 6/7/2017, physician's report had no signature and file is missing safeguard and consent. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.