Routine inspection·October 20, 2021

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Ralph Estanislao, Administrator Assistant, and Alicia Tongol, Staff. LPA 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 three (3) hospice waivers. Current resident census is four (4). 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. The facility consisted of vaulted ceilings with three (3) bedrooms, two (2) bathrooms, open living room, dining room next to the kitchen, laundry room, outdoor patio and a storage shed in the backyard. No garage. The kitchen is clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. Stove tops are in working condition. Residents' bedrooms have dresser, chair and closet space available. Adequate linen and personal hygiene supply are observed. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. Hot water temperature was in a range of 118.2 degrees Fahrenheit which was within Title 22 Regulation guidelines. Adequate linen and personal hygiene supplies. (-continued in LIC 809 C-) Dual combo of smoke and carbon monoxide detectors are operable. Fire extinguishers are fully charged. Auditory devices are operable. The first aid kit is fully stocked. Mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication is centrally stored. Resident records are stored in a locked storage room and inaccessible to residents. There are no pools and bodies of water on the premises. There are no firearms on the premises. Facility maintains a comfortable temperature of 73 degrees Fahrenheit for residents. Deficiency is 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.