Routine inspection·June 23, 2021

Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 06/23/2021 to conduct a Required-1 Year Inspection utilizing the infection control domain. LPA met with Lead Staff, Allan Gacusan, and explained the purpose of the visit. Prior to initiating the annual inspection, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment at the facility with Lead Staff. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility. LPA toured the interior and exterior of the facility together with Lead Staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, five (5) resident bedrooms, three (3) bathrooms, kitchen, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Lead Staff completed the infection control domain and facility was found to be in substantial compliance at this time. LPA requested for Lead Staff to submit requested documents to Community Care Licensing by 06/29/21. LIC 308 Designation of Administrative Responsibility Administrator Certificate LIC 610E Emergency Disaster Plan LIC 500 Personnel Report No deficiencies are being cited as a result of todays inspection. Exit interview conducted and copy of report left at the facility.