Routine inspection·October 5, 2021

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Required - 1 Year Annual visit. The primary focus is on the Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Bunker called the facility and spoke to Licensee Roneilio Garcia via telephone to conduct a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA Bunker met with Licensee Roneilio Garcia and explained the purpose of today's visit. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA observed a sanitizing station at the facility garage entrance; visitors log with COVID-19 screening and temperature log, and records of daily COVID-19 screening and temperature checks of residents and staff. PPE supplies are readily available to staff, and an additional over 90-day supply of PPE is stored in the storage closet; sufficient paper, cleaning, and disinfecting supplies were observed. LPA reviewed the facility’s surveillance testing records. LPA verified that the facility has an approved Mitigation Plan Report. Mr. Garcia stated staff and residents are fully vaccinated. All staff has completed the N95 fit testing requirement. The facility is licensed for six (6) non-ambulatory bedridden residents and an approved hospice waiver for six (6) residents. See continued LIC809-C on page #2 Continued LIC809-C page #2 Licensee Mr. Garcia and LPA Bunker toured the entire facility inside and outside grounds. The facility is a single-story family home located in a residential neighborhood. The facility consisted of the following: Living room, dining room, kitchen, six (6) bedrooms, three (3) bathrooms, laundry area in the garage, indoor/outdoor activity area, patio shaded area, attached two (2) car garage, front and back yard landscape is in good condition at the time of visit. Documents were posted as mandated. During the tour, LPA Bunker observed the facility’s infection control practices. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture. The resident's bedrooms were inspected for, safety, privacy, and comfort. The living areas are clean, bathrooms are clean and operational. First aid kit is fully stocked with manual, hot water temperature 112 degrees Fahrenheit, working telephone, smoke and carbon monoxide detectors were in compliance, fire extinguishers are fully charged, records medications is centrally stored and properly locked in the kitchen, with current record, ample supply of perishable and nonperishable food, adequate linen supply, fire/emergency drill conducted on 05/03/2021. No firearms on the premises, resident's bedroom windows have no sliding window locks with thumbscrews, all exit doors were in compliance, covered trash cans, and no bodies of water present. Hazardous items are inaccessible to residents, the yard is free of debris and hazards. Licensee Roneilio Garcia states staff was given training on dependent adult and elder abuse reporting. There were no deficiencies cited. Exit interview conducted.