Routine inspection·October 29, 2021

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced Annual Inspection visit today, and met with administrator(ADM) Merife Duewel. Upon Arrival, LPA called the front desk to open the main entrance door. The facility front desk staff took LPA's body temperature, asked the infection control questionnaires, and checked LPA in the visitor log book. LPA toured the facility inside out with ADM. LPA observed the COVID posters in facility. LPA observed many hand sanitizers in the facility. LPA toured the dinning noon, common area, activity room. Trash cans were observed with covers. LPA toured the resident rooms in Assistant LIving Unit, and Memory Care Unit. The beds in shared rooms were observed 6 feet apart. The trash cans in resident rooms were observed with covers, but some trash cans in the restrooms of resident rooms were observed without covers. ADM stated the facility will fix this in two weeks. All staff were observed wore masks. All the resident rooms have a closet with hand sanitizers and PPE in front of the bedroom door. Hand sanitizers were observed by all the elevators. Medication closet in Medication carts were observed locked. Room temperature was at 73 degree F. The check dates of Fire distinguishes were observed within one year. Hot water temperature was at 117 degree F. Smoke detectors were checked and all were working. LPA toured the courtyard, nothing was observed abnormal. Page 1 of 2. Continued on page 2 of 2. LPA checked the PPE supplies, PPE supplies were observed sufficient. LPA checked the food supplies. 2 day perishable food supplies and 7 day nonperishable food supplies were observed sufficient. LPA discussed LIC808 with ADM. ADM stated all the residents and staff are fully vaccinated. ADM stated the residents and staff who had Pfizer vaccines already received the booster shots. ADM stated the residents and staff who had Johnson and Johnson or Moderna vaccines were scheduled for the booster shots. ADM stated the facility already had the N95 fitting test for all staff. No deficiency or allegation was issued today. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of this report was emailed to ADM. Page 2 of 2.