Routine inspection·January 20, 2022

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 1/20/22 at 9:00AM. Administrator Certificate expires 6/2/2023. LPA met with Rosmerry Manariangkuba, Caregiver who contacted the Administrator Taty Sael regarding the purpose of todays visit. The facility is licensed for a capacity of 6 Non-Ambulatory residents. Taty Sael arrived within 15 minutes to assist with todays visit. Facility has a hospice waiver approved for 3 residents. At this time there are 0 residents receiving hospice services. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed and interviewed residents during this visit. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 111.7*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, pull alarm system, 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) Personnel Report (LIC500) Administrator Certificate-Updated Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited during this visit. An exit interview was conducted. A copy of this report was provided.