Routine inspection·November 3, 2021

On 11/03/2021 around 12: 50 PM, Licensing Program Analyst (LPA) T. White spoke with facility staff regarding facility risk assessment questions. Facility staff confirmed no staff or clients have experienced symptoms within the last 10 days. At 2:25 pm, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with facility staff, Josie LLarenas and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 115.2 and 111.8 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on March 09, 2021. First aid kit was observed to be complete. LPA observed completed mitigation plan. LPA reviewed 3 residents files and 3 staff files. - LPA observed fire drill last conducted November 2020. - LPA observed Staff #3 is cleared, but not associated to facility. Report continues on 809C. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/12/2021: LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. Exit interview conducted with facility staff. Exit interview conducted and Appeal rights given.