Routine inspection·August 25, 2022

On 8/25/22 at 8:55 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry. LPA met with Licensee Honora Gamueda. One staff and five residents were present during the inspection. LPA toured inside and outside of the facility. Facility observed without any obstructions or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and no residents share a room. LPA checked residents’ medications and observed the month's supply. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Staff records were reviewed for good health. Administrator certificate is valid. The following deficiencies were observed: 1. Fire extinguisher last purchased 10/8/2020. 2. LPA observed black mold in east hall bathroom bathtub caulking, in caulking of tiles around bathtub spout, and soap scum on tile wall surround; black mold in grout lines of tile wall surround in west hall bathroom; and east hall bathroom shower head observed with brown residue. 3. Hot water in east hall bathroom measured at 100.9 degrees F The following forms are to be submitted to CCL within two weeks: LIC500, LIC610E Deficiencies are being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and Plans of Corrections were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with Licensee Honora Gamueda, whose signature on this form confirms receipt of these documents.