Routine inspection·September 9, 2021

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - Annual visit on 9/9/21 at 1:45PM. Administrator Certificate expires 7/8/22. LPA met with Christine Aducayen regarding the purpose of todays visit. The facility is licensed for a capacity of 6 Non-ambulatory of which 1 may be bedridden. Facility has a Hospice Waiver for 6. At this time there are 1 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 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 108.7*F which is within the required range of 105-120*F. LPA observed 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) Liability Insurance Personnel Report (LIC500) Administrator Certificate-Updated Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited. An exit interview was conducted. A copy of this report was provided.