Follow-up·May 17, 2021

Licensing Program Analysts (LPA's) Ashley Boothe and Tirzah Hubbard conducted an unannounced visit to on 5/17/2021 at 1:00pm. LPA's met with Staff one (S1) and identified the purpose of the visit. LPA Boothe conducted facility COVID assessment with Administrator prior to today's visit via telephone call at 11:59am . LPA Boothe contacted Administrator who stated they were unable to come to the facility and designated S1. LPA's were allowed entry to the facility. Three of three staff observed cleared in Licensing Information System. Current census 6 and 0 Hospice residents. At 1:00pm LPA's observed S1 not wearing a mask while working in the facility and did not screen LPA's for COVID precautionary measures. S1 put on a mask upon LPA's request. At 1:15pm LPA's observed Staff two (S2) and Staff three (S3) not wearing a mask while working in the facility. S2 and S3 put on a mask upon LPA's request. S1, S2, and S3 stated they had just finished lunch and forgot to put it back on but wear them. S1 screened LPA's temperature LPA's signed visitor log during the visit upon LPA's request. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. Civil penalties shall be assessed when the licensee fails to correct the violation to Health and Safety Code Section 1569.605 following any appropriate extensions to the plan of correction due date. The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. Exit interview held and a copy of report was given.