Routine inspection·June 21, 2021

Prior to arrival at facility Licensing Program Analyst (LPA) Victoria Brown asked the Licensee the following questions: In the last 10 days, has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms not associated with a pre-existing condition? Fever or chills, Cough, Shortness of breath/difficulty breathing, Fatigue, Muscle or body aches, Headaches, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, and Diarrhea. Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? LPA received a "No" answer to all of the above questions. Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 6/21/21 at 12:45PM. LPA met with Agnes Melchor, Caregiver and stated the purpose of todays visit. The facility is licensed for a capacity of 6. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed residents and visiting families during this visit. See 809C for continuation... 809 continued... LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 72*F which is within the required range of 68-85*F. The hot water temperature was measured at 112.9*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. There are no residents receiving hospice services at this time. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Upon a file review the following items were discussed to be submitted with any changes annually: Designation of Facility Responsibility (LIC308) Emergency Disaster Plan LIC610E & LIC610ES Liability Insurance Personnel Report (LIC500) Administrator Certificate-Updated Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given