Routine inspection·January 17, 2024

On 01/17/2023, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with caregiver Leo Sison and explained the purpose of today's visit. LPA was informed upon entry that there is one COVID positive resident in care at this time. The resident is quarantined in their room. Infection control protocols are discussed and testing of residents and staff are conducted weekly. LPA was allowed entry into the facility. This is a one level facility. Annual Fees are not current per review made on 01/09/2023 of facility file. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is organized and observed appliances are in good repair. Knives are stored under the kitchen sink locked and not accessible to residents. Spray bottle type cleaning supplies are also locked below the kitchen sing. Cleaning solutions are also locked in a cabinet outside of the facility adjacent to the washer and dryer. Perishable and non-perishable food items are observed as in place. LPA observed the medications as in place and locked in a closet. The first aid kit observed as complete with required items. LPA observed that the facility is equipped with, fire extinguisher located the back door adjacent to the kitchen, smoke detector/carbon monoxide detectors are observed in place in resident rooms and central hallway connecting resident rooms, and central heating system is operating. PPE and additional food supplies are observed as in place in the exterior shed of the facility. Laundry area is also observed as fully operational located outside of the facility under sheltered roofing. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 112F in common resident bathroom. Continued on next page. LIC809C - Annual LPA observed several resident rooms at random and all rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. COVID PPE and resident incontinence supplies are observed in place inside the facility as well as in storage areas outside of the facility. Disaster drill is conducted quarterly, last conducted on 06/06/2023. Facility does not handle resident monies. Administrator certificate is observed as expired on 10/05/2018. The following updated forms are being requested to be received by 01/24/24 : • LIC610D Emergency Disaster Plan • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report • Updated administrator certificate • LIC9020 Client Roster • Certificate of Liability Insurance Citation issued on the following LIC809D. Report is reviewed with Leo Sison.