Routine inspection·July 12, 2023

LPA Audrey Jeung toured facility and grounds. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete. This facility is one level, with 5 client bedrooms, 2 full bathrooms, 1 half bathroom, kitchen, living/dining room, staff room, and attached 2-car garage, where the washer and dryer and an enclosed room are located; the garage room is used as sleeping room for staff, and has an exit door. Staff room has two beds. The backyard is paved and enclosed by a stone wall in the back and wood fence on the sides. There is a storage shed in backyard. Medications are stored in locked kitchen cabinet and chemicals and cleaners are stored in locked garage cabinet. An updated Disaster and Mass Casualty Plan is posted, and copy is given to LPA. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Julita Andaya and Wilma De Guzman are certified RCFE administrators (x 2/25 & 5/24) that oversee facility operations. Client records and Staff training records will be reviewed at a later date. The following forms are provided and shall be completed and returned to CCL by 7/28/23: • LIC 308 Designation of Administrative Responsibility, including Board resolution • LIC 309 Administrative Organization • LIC 500 Personnel Report • LIC 610 Emergency Disaster Plan (signed and dated) • Infection Control Plan (signed and dated) • Proof of liability insurance for $1 million per incident and $3 million in annual aggregate • Control of property/valid lease agreement Deficiencies of the CA Code of Regulations, Title 22 are cited on a following page. Also, see 3 Advisory Notes issued.