Routine inspection·October 5, 2021

On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by caregiver Lady Manieda and explained the nature of the visit. During today's visit, LPA Quiroz called and spoke to Administrator (AD) AD Rita Lee. AD Lee indicated not being able to be present at today's Annual inspection due to a pre planned scheduled appointment. On or about 11:40am, Caregiver Anne Villanueva arrived to facility and indicated she would be assisting during today's annual inspection. This facility is licensed to provide services to 6 Non-Ambulatory Residents, of which one (1) may be bedridden and has a hospice waiver for four (4) residents. Administrator Rita Lee has an Administrator Certificate with expiration date of 7/31/2020, and indicated she enrolled today to renew Administrator certificate, and will provided proof of enrollment by COB. On or about 11:11am LPA Quiroz along with Caregiver Manieda toured the inside and outside of facility. Two staff working at facility were observed to be wearing face masks upon arrival to facility. There are five residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed four residents in their bedrooms resting and one resident in living-room area resting watching television. LPA Quiroz observed five of five residents in care appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. CONTINUED ON NEXT PAGE... Facility has back-up emergency food supply as well PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment. Facility has completed the LIC 808 Mitigation plan and LPA Quiroz approved the plan on today’s visit. During today's inspection visit, LPA Quiroz reviewed five of five resident records. Administrator Lee indicated "all residents and staff at facility are vaccinated for COVID-19 at this facility." Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. Technical Violation LIC 9102 was consulted with AD Lee via telephone and with aregiver Anne Villanueva during today's visit. This report was reviewed with Caregiver Anne Villanueva, and a copy of this report was provided to Caregiver Villanueva at exit.