Routine inspection·August 3, 2022

On 08/03/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff informed LPA that Administrator was not present in the facility. Facility staff contacted Assistant Administrator (AA), Elisa Pua, who arrived a short time later. Facility tour conducted with AA. All pathways, entrances and exits were clear from obstructions. No fire clearance issues. LPA observed signs promoting hand-washing, social distancing, and cough/sneeze etiquette throughout facility. Facility staff observed to be wearing facial coverings. LPA toured the facility kitchen. LPA observed an adequate supply of food. LPA observed a 30 day supply of PPE and cleaning supplies. Hand- sanitizer is readily available. Facility has 4 bedrooms, 2 bedrooms are single occupant and 2 bedrooms are double occupant. Facility bathrooms were stocked with paper towels and liquid soap. Hand-washing signs were observed in resident bathrooms. LPA checked residents' medication and observed a 30 day supply. LPA observed refrigerated medications to be accessible to residents in care in a box in the refrigerator. Resident records have updated emergency contact information. Facility staff records reviewed for good health. LPA is requesting the following documents be submitted to the Fresno CCL office by 08/17/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond. CONTINUED TO LIC809C Based on observation, a deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D Exit interview conducted and a plan of correction was reviewed and developed with Assistant Administrator. A copy of this report and appeal rights were discussed and provided to Assistant Administrator, Lisa Pua, whose signature on this form confirms receipt of this document.