Routine inspection·December 10, 2021

Licensing Program Analysts (LPA's) Sabrina Calzada and Cassie Yang, arrived unannounced to conduct a required annual. LPA met with Anna Burton, caregiver and explained purpose of inspection. LPA's were screened for temperature check at the door and asked to sign-in per Covid-19 precautionary measures. Caregiver contacted Marnelli "Nellie" Johnson, Administrator, who arrived shortly to the facility. LPA's completed required COVID-19 testing protocols and completed daily assessment and confirmed the facility does not currently have any positive Covid-19 diagnoses. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask. The facility is approved for (6) residents and (1) resident is currently on hospice. LPA's observed (3) residents in the common area and (2) residents in their private room. LPA's and Administrator toured the interior of the facility, including (6) private resident rooms, (2) common restrooms,, kitchen, laundry, caregiver room, and common areas. LPA's observed it to be clean and in good repair. LPA's observed various Covid posters throughout. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA's and Administrator completed the infection control domain and facility was found to be in compliance at this time. Inside temperature was observed to be 71* F. Fire extinguisher last serviced 12/30/2020. LPA's observed sufficient 2+day perishable and 7+day non-perishable food. LPA's observed paper towels, soap, sanitizer and covid posters in the restrooms. Administrator to ensure all restrooms have a trash can with lid. LPA's observed ample PPE supply. Sharps, Toxins and medications were secured. LPA's observed required postings in the facility. LPA's and Administrator discussed vaccination status of residents and staff as well as visitation protocols per PIN 21-40. LPA's observed signage/information posted at the front entrance that masks, documentation of vaccination status or negative Covid test within 72 hours are required upon entry. LPA requested an updated copy of LIC308 (copy printed) and obtained a current copy of liability insurance and LIC500. There were no deficiencies observed during today's inspection. Exit interview. Copy of report provided to Administrator.