Routine inspection·May 26, 2021

Licensing Program Analyst (LPA), Shobhana Frank , made an unannounced visit to the facility to conduct a required - 1 Year inspection. LPA Frank was granted entry into the facility by Licensee Linda Bolivar. LPA Frank reviewed the facility file, reviewed Mitigation plan – LIC 808 –Mitigation Plan prior to visit. LPA complete Facility Risk Assessment prior to the visit. A tour of the facility was conducted inside and out of physical plant. Three staff and five residents were present at the time of inspection. Facility has a capacity of six (6) residents, ages sixty (60) and above. The facility is operating in the capacity and conditions approved by CCL. There is no pool or bodies of water accessible to residents in care. Facility is a single story structure which has the capacity of retaining 6 residents. This facility has 5 bedrooms and 2 bathroom, 2 bedrooms are private 2 shared bedrooms and 1 staff room. LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log. LPA observed COVID posters throughout the facility. LPA observe the facility to be clean and in good repair. Physical Plant and Safety of Environment/Operational Requirements. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 109.2 degrees F. Grab bars, non-slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap, Sufficient PPE supplies and other chemicals in the garage. On 5/21/21 facility conducted surveillance Testing and results are negative. Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medical and Dental- LPA reviewed two resident file, two clients interviews were conducted. facility is meeting documentation requirements. Resident Rights are posted in the facility and a copy is signed on file. Dementia and hospice regulation requirements are being met. Personnel Records/Training/and Staffing- LPA reviewed two employee records. CPR and annual training requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the residents in care. The facility administrator is present a sufficient number of hours to maintain the facility. Administrator certification is present. Food Service- The meal is adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair. Fire extinguishers are charged, mounted and expires on 4/1/2022. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility is maintained in conformity with the regulations adopted by the state fire marshal. The facility does not handle resident money. Based on the information received during this visit today, there are no deficiencies being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative.