Routine inspection·October 7, 2022

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met Ralph Estanislao, Administrator Assistant. 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. Two (2) residents are on hospice. Administrator certificate is current and expiration date is 3/22/2024. 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. The facility is a single story house located in a residential neighborhood in Covina consisted of 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. Residents' bedrooms have dresser, chair and closet space available. Adequate linen and personal hygiene supply are observed. Adequate linen and personal hygiene supplies. Bathrooms inspected were clean, operable, with the required grab bars and non-skid materials in the shower. 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. Hot water temperature was in a range of 114.3 degrees Fahrenheit which was within Title 22 Regulation guidelines. Facility maintains a comfortable temperature of 72.4 degrees Fahrenheit for residents. (-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. No 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.