Routine inspection·July 30, 2021

Licensing Program Analyst (LPA) Victoria Brown and Brittney Ross, Seasonal Clerk arrived unannounced to conduct a Required - Annual visit on 7/30/21 at 11:45am. The Administrator Certificate expires on 3/22/2022. LPA met with Ruperto Rosario, Caregiver and Regina Rosario who assisted with todays visit. LPA discussed the purpose of the visit. Licensee was notified of the visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 3 may receive hospice services. There is 2 residents receiving hospice services at this time. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and interviewed a random amount of residents who were engaged in lunch and individual activities 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 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 107.9 *F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. 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) LIC610E to be updated Liability Insurance Administrator Certificate-Updated Personnel Report (LIC500) Facility Roster to be updated Administrative Organization LIC309 Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.