Routine inspection·December 22, 2021

Licensing Program Analyst (LPA) Christine Wong conducted an annual required visit. LPA met with the administrator/licensee Percy Oldian and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications, observed the food supply, and reviewed resident and staff files. Facility has submitted a mitigation plan and was approved 07/22/2021. The facility is located at a residential neighborhood. The facility consists of three(3) residents rooms, two (2) live in staff bedrooms, two (2) residents bathrooms and two (2) live in staff bathrooms, living room, dining area, kitchen, mini library, patio and a detached garage. Resident Room#1 and #2 has two beds, two night stand, two drawers and sufficient closet space and lighting. Currently Resident Room #3 is used as storage due to the facility only has 3 residents. The two residents bathrooms were toured. Bathroom has required grab bars and non-skid mats. The hot water temperature tested between two residents bathrooms was 106.3 and 108.3 degrees F which is within the Title 22 regulation. While LPA inspected the resident bathroom#1 and observed there were many ants in the bathroom. The food in the kitchen and the patio has sufficient food for two days perishable and seven days non-perishable. All the appliances are clean and working properly. The common area such as living room and dining area are clean and have the required furniture. The front and back yard are maintained well. LPA reviewed 3 resident files to confirm emergency contact is updated. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. Resident #1 (R1's) Divalproex Sodium 500mg was not stored in the original container and it was stored in another pill box. The deficiencies cited are documented on the attached 809D. A copy of the report and appeal rights will be provided to the administrator.