Routine inspection·December 28, 2021

Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Caregiver Nero Kaw and explained the reason for the visit. LPA Frank toured the facility. There are four residents residing in the facility and no active COVID-19 cases. LPA observed four residents on site. All residents appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. Facility is taking residents temperatures and documenting results. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. Facility has completed the LIC 808 Mitigation Plan. No citations noted during today's visit. Exit interview conducted and a copy of this report was provided.