Routine inspection·June 23, 2021

On 6/23/2021, Licensing Program Analyst (LPA) Leslie Ibo arrived unannounced to conduct an annual required inspection. LPA met with staff Hazel Karingal and informed the purpose of visit, while conducting facility tour, Administrator Ian Frederick Salalila joined LPA on facility tour. Facility has census of 5. LPA toured the facility inside and out including but not limited to common areas, resident rooms, bathrooms, kitchen and backyard. Facility has enough supplies of paper supplies and hygiene supplies. Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. Facility has enough 2-day perishable food and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a mitigation plan. .....Continued to LIC809C.... LPA observed the following: Licensee has not provided all staff with fit testing for N95 respirators- Administrator will order fit testing kit for the facility, Administrator will send proof of training to LPA by July 9, 2021. Routine symptom screening (+/- temperature and symptom check) has been NOT initiated at entry for all staff, residents, and visitor . – Administrator will create a binder that will document routine covid19 screening questions for all staff, residents and visitors. Facility does NOT documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread of infection. - Administrator will create a binder to document daily temperature screening questions for all staff & residents. A sign-in policy has NOT been enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing) - Administrator will create a binder for sign- in policy using covid19 screening questions for all staff, residents and visitors. Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with Administrator Ian Frederick Salalia. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided