Routine inspection·July 11, 2022

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 (CG) Ted Nichols Abapo and met with Assistant Administrator (AA) John Jason Eugenio and explained the nature of the visit. Facility indicated screening all incoming visitors prior to entering the facility. Facility is licensed to provide services to Age range 60 and over, 6 Non Ambulatory residents of which (1) one may be bedridden, and has a Hospice Waiver for (5) five residents. Facility currently providing services to three (3) residents on hospice. Administrator Brian Estorba has a current Administrator certificate with expiration date of October 12, 2023. On or about 3:37pm, LPA Rosie Quiroz along with (AA) John Jason Eugenio began the tour of the inside and outside of the facility. There are six (6) residents in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed two of six residents in the living-room area resting supervised by caregivers, and four of six residents observed to be resting and watching television in their private bedrooms. LPA Quiroz interacted and interviewed with resident's during today's visit. Six of six residents appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility; LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 72 degrees fahrenheit. All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within 79-84 degrees Fahrenheit. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area for residents and visitor's enjoyment in backyard area. Continued on next page... The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received by the Department on January 20, 2021. During today's visit, LPA Quiroz reviewed and approved LIC 808 Mitigation Plan dated January 20, 2021. LPA Quiroz was informed that all residents and staff have had their COVID-19 vaccinations and first Booster and coordinating with resident's families about second booster vaccination. Facility indicated to be recording resident's temperatures daily. During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit. Based on the observation made during today’s visit, deficiency was noted today per Title 22 Division 6 of the California Code of Regulations. (SEE LIC 809-D) This report was reviewed with (AA) John Jason Eugenio, and a copy of this report, Appeal Rights and LIC 811 Confidential Names were provided at exit.