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 Licensee/Administrator (L/AD) Lumauig "Connie" Consolacion and explained the nature of the visit. This facility is licensed to provide services to residents age range 60 and over, 6 Non-Ambulatory Residents and has a hospice waiver for four (4) residents. L/AD Consolacion has an Administrator Certificate with expiration date of 08/08/2021. L/AD Consolacion indicated she completed Administrator recertification, and is still waiting for new Administrator Certificate. L/AD Consolacion has agreed to submit new Administrator certificate to Community Care Licensing (CCL) upon receiving it. On or about 10:06am LPA Quiroz along with L/AD Consolacion and Administrator Assistant Edison Sadraca toured the inside and outside of facility. There are six residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed four(4) residents in living-room area resting watching television. Two residents were observed in their bedrooms resting. Six of six 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. L/AD Consolacion and Administrator Assistant Sadraca 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 LIC808 Mitigation plan dated 3/21/2021. During today's visit, AD Consolacion and Administrator Assistant Sadraca made additional updates on page 11 of their mitigation plan and resubmitted it to CCL. LPA Quiroz received new updated LIC 808, and approved LIC 808 during today's visit. During today's inspection visit, LPA Quiroz reviewed six of six resident records. L/AD Consolacion indicated "all residents and staff at facility are fully vaccinated for COVID-19, and will be scheduling booster shots soon." 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. This report was reviewed with L/AD Consolacion and Administrator Assistant Edison Sadraca, and a copy of this report, LIC 811, LIC 9102 were provided at exit.