Routine inspection·October 26, 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 Esther Forsyth and explained the nature of the visit. Upon arrival to the facility, LPA Called and spoke to Licensee/Administrator Louie Dormido via telephone and explained nature of the visit. Administrator (AD) Kenneth Forsyth arrived to facility shortly after and met with LPA Quiroz. This facility is licensed to provide services to residents age range 60 years and over, 6 Non-Ambulatory Residents and has a hospice waiver for two (2) residents. AD Kenneth Forsyth has an Administrator Certificate with expiration date of 02/15/2023. On or about 1:22pm LPA Quiroz along with AD Kenneth Forsyth toured the inside and outside of facility. There are five residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed one (1) resident in living-room area resting watching television. Three residents were observed in their bedrooms resting. AD Forsyth indicated R1 is currently not at the facility and is at a Skilled Nursing Facility. Four of five residents 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. AD Forsyth indicated facility is taking temperatures daily; however not documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment. CONTINUED ON NEXT PAGE... Facility has completed the LIC 808 Mitigation Plan. During today's visit, LPA Quiroz reviewed LIC 808 Mitigation Plan . LIC 808 requiring changes/updates. AD Forsyth agreed to discuss LIC 808 with L/AD Louie Dormido, update and resubmit LIC 808 Mitigation plan to CCL by 10/30/2021. During today's inspection visit, LPA Quiroz reviewed five of five resident records. AD Forsyth indicated "all residents and staff at facility are fully vaccinated for COVID-19." 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. LIC 9102 Technical Violation was provided during today's visit for COVID-19 guidance. (SEE LIC809-D) This report was reviewed with Administrator kenneth Forsyth, and a copy of this report, LIC 811, LIC 9102, LIC 809-D and Appeal Rights were provided at exit.