Routine inspection·August 5, 2022

At approximately 10:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-year required Annual Visit and met with Administrator, Jolly Carungcong. The inspection is focused on the Infection Control procedures and practices of this facility. Upon arrival at the facility, LPA had their temperature checked and logged. LPA did not answer a COVID-19 Questionnaire. Per conversation with Administrator, Facility stopped using the questionnaire in February 2022. LPA and Administrator discussed the importance of having the questionnaire available to visitors in the event a COVID outbreak occurs. LPA conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the public bathrooms and at sinks. Hand Sanitizer was readily available for use throughout the facility. Toxins and detergents were secured and inaccessible to residents. Medications were located in the medication room that was locked and inaccessible to residents. All staff present were observed to be wearing a mask. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. LPA and Administrator discussed facility's plan for staffing if a shortage occurred. Facility has a cleaning and disinfecting schedule that occurs two to three times per day. Facility has at least a 30-day supply of PPE and medication for residents. Staff and residents are screened daily for COVID-19 symptoms and it is logged into facility binders. LPA and Administrator discussed PIN-22-13-ASC regarding Infection Control Plans. Continued on LIC 809-C Continued from LIC 809 LPA observed that 6 of 9 fire extinguishers were last serviced on November 1, 2021. However, 3 of 9 fire extinguishers showed service tags that were outdated, expired, and last serviced on May 6, 2019. Per conversation with Administrator, the Fire Department conducted an inspection in May 2022. LPA was provided with the Fire Department Invoice dated for May 27, 2022 stating that the next extinguisher service will be conducted in November 2022. Administrator called Fire Department during visit to clarify outdated fire extinguisher tags since an inspection was recently conducted. Fire Department will be coming to facility at a later date to check fire extinguishers. LPA and Administrator discussed the importance of having their fire extinguishers checked yearly per regulation. Fire Alarms and Carbon Monoxide detectors were last tested during a fire drill conducted on 4/11/2022. Facility has a central pull fire alarm system that is directly connected to the Fire Department. LPA provided with a copy of Fire Drill form. LPA Felias requested the following documents to update facility file: Copy of Lease Copy of Liability Insurance Certificate Copy of Personnel Report (LIC 500) Copy of Surety Bond (LIC 402) if appliable Documents requested to be submitted by Close of Business on Friday, September 2, 2022. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC 9099-D, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.