Routine inspection·September 1, 2022

On September 1, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front door. LPA met with Caregiver/Assistant Administrator, Lolita Factolerin and explained the purpose of the visit. Caregiver was able to provide screening log documentation for residents and staff. LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 6 resident rooms and 1 full bathroom. All resident rooms were observed to be private rooms and 5 resident rooms were observed to have half bathrooms. LPA observed full bathroom to be equipped with liquid soap, paper towels, hand-washing signage, and a trash can with a lid. LPA toured the kitchen and observed toxins, medications, and sharps locked and inaccessible to residents. 2 day perishable and 7 day non-perishable was present. Infection control practices are reviewed: COVID signage throughout the facility, face coverings, 30-day PPE supply, visitor sign in, and daily monitoring records for staff and residents. LPA toured the living room and dining room and it was clean and odor-free. The living room was clear from any tripping hazards. A comfortable temperate at 72 degrees F was maintained. Lighting was sufficient for comfort. LPA observed the first aid kit to be completed and extra linen to be present. Washer and dryer was observed in the garage to be in good working condition. 30-day PPE supply and extra food supply was also present in the garage. During the visit, LPA observed a room that was built in the garage that was not indicated on the facility floor plan. According to the Caregiver, this room in the garage is being utilized as a staff room. LPA advised caregiver to have facility administrator submit an updated facility floor sketch as prior facility floor sketch indicated one of the six rooms in the facility was a staff room. In addition, facility floor plan did not show a staff room in the garage. LPA requests the following forms to be submitted to CCLD by 9/8/22: LIC308 Designation of Administrative Responsibility LIC500 Personnel Report Administrator Certificate LIC610E Emergency Disaster Plan Updated facility floor plan Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Caregiver and a copy is provided with appeals rights.