Routine inspection·May 18, 2022

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator, Mary Jane Mendoza. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. There are currently 4 residents in care. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 2 of the residents and none of the residents are approved for bedridden. LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas to promote hand washing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was reviewed by Community Care Licensing department on 7/21/2021. Caregivers have completed PPE training but have not been N-95 Fit tested. In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguisher was found to be charged and serviced 6/2/2021. Continue report see LIC809-C LPA requested the following updated records to be submitted to Community Care Licensing by 6/15/2022 · LIC 308 Designation of Facility Responsibility · LIC 500 Personnel Report · LIC 400 Affidavit Regarding Client/Resident Cash Resources · LIC 402 Surety Bond · LIC 610D Emergency Disaster Plan · LIC 9020 Register of Facility Residents · Copy of current Administrator's Certificate · Copy of current Lease/Rental Agreement or Property Tax document showing control of property. Exit interview conducted with Mary Jane Mendoza, Licensee/Administrator. No deficiencies cited during this inspection