Routine inspection·May 28, 2021

LPA Audrey Jeung toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Julita Andaya is a certified RCFE administrator (x 2/23) that oversees facility operations. The following updated forms/information are requested to be submitted to CCLD BY 6/4/21: • LIC 308 Designation of Administrative Responsibility • LIC 309 Administrative Organization • LIC 500 Personnel Report • LIC 999 Facility Sketch • LIC 610D Emergency Disaster Plan • Proof of current liability insurance Ms. Andaya is advised that Personal Rights form (LIC613C-2) has been revised to include Health and Safety Code 1569.269, non-discrimination (LGBTQ) notice, AND Centralized Complaint and Information Bureau (CCIB) contact information. This information must be posted prominently in facility, and LIC613C-2 must be signed by resident or his/her representative. Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.