Routine inspection·November 2, 2021

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Dominga Santillian and explained the reason for the visit. Administrator/ Licensee Jay Pichika arrived during the visit. At 10:00 AM, LPA toured the facility with Caregiver Santillian. Administrator Pichika joined the tour in progress. Facility has three residents in care during today's visit. LPA observed residents relaxing in their rooms or in common areas. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. At 10:10 AM, LPA observed a floor tile coming up in the master suite. Hand washing signs are posted throughout the restrooms. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as most required department postings. Administrator Pichika has an administrator certificate that expired on 09/13/2019. LPA observed a bed and discarded items sitting on the driveway as well as an ramp needing repair (photos). LPA toured the kitchen and observed ample food supply as well as emergency food and water. At 10:20 AM, LPA observed a broken cabinet door in the kitchen as well as missing molding on the top of kitchen cupboards. Facility has completed the mitigation plan and the plan has been approved. LPA observed the first aid kit contained all required items and medications are stored secured in a locked cabinet. LPA toured the outside grounds and observed the outside visitation area. LPA observed a patio set with broken cushions and table decorations are peeling off the table. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed all files which contained required documentation including emergency information and updated physician reports. LPA consulted with Administrator regarding the importance of maintaining an ample supply of N95 masks on-site at all times. Based on the observations made during today's visit, CONTINUED ON LIC 809C DATED 11/02/2021 the following violations are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with facility representative.