Routine inspection·March 10, 2022

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced to conduct an 1 Year Annual Inspection visit. LPA explained the purpose of the visit to Licensee/Administrator Lani Calagui. Administrator Certificate Expires 01/28/2023. LPA Wallace inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 6. LPA also conducted the infection control domain tool. Facility has 4 bedrooms. All resident rooms are shared. There is a separate room for staff use only. Facility has 2 bathrooms and a formal dining area and separate living and TV room. All resident rooms are located down one hallway. No obstructions to emergency exits noticed. All sharps and toxins are secured and inaccessible to residents in care. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing, COVID-19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a COVID-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. Water temperature reads 115.3*F in the bathroom and room temperature reads 76*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher expires 7/1/22. Facility has an emergency food and water kit. LPA Wallace is requesting the following documents to be submitted via email by May 10, 2022: LIC 308- Designation of Administrative Responsibility, LIC 500- Personnel Report, LIC-610E- Emergency Disaster Plan, Copy of Deed, and Facility Program/Plan of Operation/Food Services/Activities/AWOL Procedures Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report was given to Licensee/Administrator.