Routine inspection·December 22, 2021

Licensing Program Analysts (LPAs) Tao and Hanna conducted an unannounced annual inspection visit. LPAs met Jasbindar Singh, Administrator and explained the purpose of the visit. The facility has a capacity of six (6) to serve residents from age 60 and above which may have six (6) non-ambulatory and approved for four (4) hospice waiver. Current resident census is three (2). Two (2) residents are on hospice. During the visit, the infection control domain tool was used, a tour of the facility was conducted, food supply was reviewed, and medications were reviewed. This home is a single story house located in a residential neighborhood in Covina . It is a single story house with a ramp and a guard rail that leads to the front entrance, The facility consisted of five (5) bedrooms, two (2) bathrooms, office, living room, dining, room, kitchen, back yard and a carport The kitchen was clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. Each resident's bedroom had a dresser, chair and closet space available. Adequate linen and personal hygiene supply were observed. Bathrooms inspected and were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 113.2 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies. (-continued in LIC 809 C-) Smoke detectors and carbon monoxide detectors were operable. Fire extinguishers were fully charged and last service was on 1/20/21. Auditory devices were operable. Fire drill was conducted on 9/30/21. Administrator certificate had an expiration date on 4/11/23. The first aid kit was fully stocked. Mandated documents and signages were posted in common areas. The outdoor activity area had a shaded patio with ample seating. Medication is centrally stored. Resident records were stored in a locked storage room and inaccessible to residents. There are no pools and bodies of water on the premises. There were no firearms on the premises. Facility maintained a comfortable temperature of 73 degrees Fahrenheit for residents. Deficiencies cited per California Code of Regulations, Title 22. An exit interview was conducted. This report is discussed and provided to facility Administrator assistant, whose signature on this form confirm receipt of these documents.