Routine inspection·May 13, 2021

Prior to today’s visit Licensing Program Analyst (LPA) Victoria Brown contacted the Licensee with the following questions: In the last 10 days, has anyone who is regularly present in the home/facility, including persons in care, or staff developed any of the following symptoms, not associated with a pre-existing condition? ​ · Fever or chills ​ · Cough ​ · Shortness of breath/difficulty breathing · Fatigue ​ · Muscle or body aches ​ · Headaches ​ · New loss of taste or smell ​ · Sore throat ​ · Congestion or runny nose ​ · Nausea or vomiting ​ · Diarrhea ​ Have any individuals Tested positive for COVID-19 with a laboratory confirmed test? ​No Have any individuals Been exposed to someone who tested positive for COVID-19 w/o wearing appropriate PPE? ​ No Have any individuals Been diagnosed with a respiratory infection (e.g., flu, bronchitis) or have any respiratory symptoms, such as a sinus congestion or runny nose? ​No Are any individuals in care, caregivers, or staff being evaluated for COVID-19 by a healthcare worker in a healthcare setting? No Have any individuals in care, caregivers, or staff been quarantined for COVID-19 in the past 30 days? No Have any individuals in care, caregivers, or staff traveled within the last 14 days, to a country considered to be at high-risk for COVID-19 by the CDC travel website? No Licensing Program Analyst(s) (LPA) Victoria Brown and Ashley Boothe arrived unannounced to conduct a Required – 1 Year inspection on 5/13/21 at 12:30pm. LPAs met with Liza Segunban, Administrator and stated the purpose of today’s visit. LPAs was allowed entry into the facility that is licensed to serve a total capacity of 34 bedridden clients. The Administrator Certificate expires on 6/30/22. There are no residents using hospice services at this time. LPAs interacted with a random number of residents during this visit. The team toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. The team observed residents participating in group activities using social distancing during this visit. The team observed the kitchen area, dining area, bedrooms, bathroom, storage areas, and laundry room. The team observed knives to be locked. The team observed required furniture, and lighting throughout the facility. LPA's observed large storage containers outside holding personal care products and decorations to be locked. The temperature inside the facility was measured on the wall thermostat at 75*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water was measured at 113.4*F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. LPA observed the centrally stored medications area to be locked and inaccessible to clients. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed the facility Emergency and Disaster drills are conducted quarterly. LPA observed food supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days which shall be maintained on the premises at all times. Upon a file review the following items were discussed to be submitted with any changes annually: Application to be updated without fees LIC200 Designation of Administrative Responsibility LIC308 Administrative Organization LIC309 Personnel Report LIC500 Health Screening Report-Facility Personnel LIC503 Emergency Disaster Plan LIC610E to include Carbon Monoxide Detector Qualifications of Administrator/Facility Manager-Certificate Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.