Routine inspection·October 8, 2021

Licensing Program Analyst (LPA) Tao conducted an unannounced annual inspection visit. LPA met House Manager, Jennifer Sandoval, and Consultant, Vanessa Ricchiazzi and explained the purpose of the visit. Co-manager, Kenny Yu, joined the visit 30 mins after. The facility has a capacity of six (6). Its fire clearance is approved for five (5) non-ambulatory, one (1) bedridden and six (6) hospice waivers. Current resident census is six (6). No resident is 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. T he facility is located in a residential area. A physical tour is conducted. The facility is a single-story home with six (6) client’s bedrooms, three (3) bathrooms, a living room, a kitchen, a dining room, an activity area, a laundry room and a garage. The kitchen is clean and has maintained the required two (2) days perishable and seven (7) days non- perishable. All burners and stove tops were 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 combos which smoke detector is combined with carbon monoxide detector are operable and hard wired. Fire extinguishers are fully charged and last service is on 7/28/2021. Auditory device is operable. The first aid kit is fully stocked. The last Fire/ Emergency Drill was conducted on 6/20/21. All mandated documents and signages are posted in common areas. The outdoor activity area has a shaded patio with ample seating. Medication are centrally stored in a locked storage room and inaccessible to residents. 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 74 degrees Fahrenheit for residents. Administrator certificate is current and the expiration date is 7/29/2023. No deficiencies cited per California Code of Regulations, Title 22. An exit interview was conducted. This report is discussed and provided to facility Consultant, Vanessa Ricchiazzi (Carrillo-Rangel), whose signature on this form confirm receipt of these documents.