Routine inspection·June 16, 2021

Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 06/16/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain, LPA met with Roland Loewen (Staff) and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted facility and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. LPA spoke with Admin and was informed Roland Loewen is approved to sign report in Lieu of Admin. LPA and staff toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, three (3) resident bedrooms, five (5) bathrooms, kitchen, and yard area. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and staff completed the infection control domain and facility was found to be in substantial compliance at this time. LPA has requested the following documents to be provided to Community Care Licensing Department (CCLD) by COB 6/30/2021 via email at Konnor.Leitzell@dss.ca.gov or via Fax at (916) 263-4744. Designation of Administrative Responsibility (LIC 308) Affidavit Regarding Clients/Residents Cash Resources (LIC 400) Current Administrator Certificate Limited Liability Insurance Neighborhood Complaint Procedures No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.