Routine inspection·November 30, 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 Thinh Pham. LPA Quiroz called Licensee/Administrator (L/AD) Mai Nguyen and left voicemail and explained the nature of the visit via voicemail message. L/AD Mai Nguyen arrived during today's visit This facility is licensed to provide services to 6 Non Ambulatory residents and has a hospice waiver for (2) residents. L/AD Mai Nguyen has an Administrator Certificate with expiration date of 7/23/2022. On or about 3:20pm, LPA Quiroz reviewed 6 of 6 resident records. On or about 3:42pm, LPA Quiroz along with L/AD Mai Nguyen toured the inside and outside of the facility. There are six (6)residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed six (6) residents in living room area listening to music on television and interacting with staff. Six of six residents present in the facility 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. L/AD Mai Nguyen indicated facility is taking temperatures daily; and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food, water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed ample seating area with tables and chairs for resident’s enjoyment in backyard area. CONTINUED ON NEXT PAGE... CONTINUED... Facility has completed the LIC 808 Mitigation plan dated 12/21/2020. The LIC 808 Mitigation Plan was approved by LPA Quiroz during today's visit. During today's inspection visit, L/AD Mai Nguyen indicated "All staff and residents are fully vaccinated and have received booster for COVID-19." LPA Quiroz reviewed 6 of 6 resident's records during today's visit. 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. This report was reviewed with L/AD Mai Nguyen, and a copy of this report and LIC 811 were provided at exit.