Routine inspection·December 21, 2021

Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct an Required- 1 year annual inspection and met with Viridiana Agapoff, House Manager and Administrator, Paulina Lopez. The annual inspection was focused on the Infection Control procedures and practices. LPA conducted risk assessment with House Manager. Administrator Paulina Lopez arrived later. LPA conducted a walk-through of the facility with House Manager. Fire Extinguishers were found to be last charged on August 3rd, 2021. There was sufficient amount of supply for both perishable and nonperishable foods. A sample of Smoke & Carbon monoxide detectors were tested and operational during visit. LPA observed COVID-19 precaution postings. LPA temperature was taken and documented on sign-in sheet. LPA advised facility to ask screening questions for all visitors, residents and staff at entrance. Visitors and staff and residents temperatures are being documented for COVID-19 symptoms upon arrival to the facility. Resident's temperatures are taken daily and documented. Staff clean and disinfect the facility at least once daily. Some staff have completed training on infection prevention, symptoms, transmission and PPE use but will schedule training for the remaining staff. The facility has a supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and disposable gowns. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was approved by the California Department of Social Services on 3/16/21. During the walk through of facility, LPA observed Resident #1 (R1) room and bathroom used partially used as a storage (photos taken). House Manager stated that they were storing Christmas supplies in R1's room. R1's bathroom tub had a toilet seat, walker and other materials (photos taken). LPA also observed restroom shower by the washer machines with a hamper inside shower. House Manager stated that facility uses the shower to put laundry in (photos taken). Continue to LIC 809C... House Manager stated that facility does not use that shower for residents. LPA observed two scissors that were accessible to residents in care and were immediately put away by House Manager. At approximately 9:43am, LPA observed toxins with lock that was unlocked and House Manager immediately locked the cabinet. House Manager stated that staff had finished cleaning. At 9:38am, LPA observed one alcohol bottle in refrigerator by resident rooms that was accessible to residents in care. House Manager stated that the alcohol was for R2. R2 drinks some alcohol during the week. House Manager agreed to lock alcohol at all times. House Manager threw away bottle of alcohol immediately. While touring facility LPA observed construction. House Manager stated that construction workers were remodeling bathrooms. Facility did not let Community Care Licensing know of this remodeling. LPA requested new facility sketch since the remodeling would change their current facility sketch. House Manager stated that the construction would be done by next week. In the meantime, facility's plan is to keep residents safe by locking door that leads to construction during construction times and will not be accessible to residents in care. LPA requested updates of construction from facility and a written plan for the resident's safety during remodeling of bathroom. During walk through of backyard LPA observed an unlocked lock on the backyard gate. House Manager stated that facility locks the gate at night for safety. LPA stated that facility cannot lock any perimeter gates without an approved waiver from Community Care Licensing and approval from the Fire Department. A waiver has not been requested or submitted at this time. House Manager immediately removed lock and Administrator and House Manager understood the requirement and stated that facility will not lock any perimeter gates. LPA requested the following documents: Administrator Certificate, LIC 309, Plan for Incidental Medical and Dental Care, LIC 9020 and LIC610 Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator, whose signature on this document confirms receipt. Report given.