Pre-licensing visit·May 19, 2022

Licensing Program Analyst (LPA) Tung Truong arrived at this facility announced on 05/19/2022 at 9:35 AM to conduct a Pre-licensing inspection. LPA Truong was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility. Upon LPAs arrival, Caregiver Tavaita Servatu was present at facility and contacted Administrator Unaisi Waqalala who arrived a bit later. LPA met with Unaisi Waqalala, Applicant and stated the purpose of today’s visit. The facility will be licensed for a capacity of 6 non-ambulatory residents. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed there were six residents in care at this time. LPA observed the temperature inside the facility was measured at 75*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 110.5*F. LPA observed 2-day perishables and 7-day non-perishables. LPA observed the centrally stored medications area, cleaning supplies, and staff files to be locked. Resident rooms were sanitary and had the required furniture and furnishings. Resident bathrooms observed to have non-skid mats, soap, paper towels, and closed lid garbage cans. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers and first aid kit were up to date. LPA observed no obstruction of emergency exits inside or outside of facility. Report continued on 809-C The facility had Covid-19 posting throughout the facility. The facility had a mitigation plan completed and provided it to Licensing for approval on 3/16/22. The facility had one central entry point, and the facility had routine symptom screening checks for residents, staff, and visitors. The facility had a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Based on a review of this facility during this Pre-licensing visit, it was determined that this facility was found to be in compliance at this time. LPA discovered that Applicant Unaisi Waqalala has completed Component III before and will therefore waive this requirement. LPA will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.