Routine inspection·September 30, 2022

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator/Licensee, Rafael Aquino. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. There are currently 6 residents in care. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 1 of the resident and none of the residents are approved for bedridden. LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas. 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 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 7/28/2021. 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 but last serviced on 4/29/2021 and not within the required yearly service. LPA consulted with Administrator, Rafael Aquino regarding a loose or weak board in the front entrance wooden path that will need to be looked at and repaired. Continue report see LIC809-C LPA requested copies of the following updated records to be submitted to Community Care Licensing by 10/30/2022. · LIC 308 Designation of Facility Responsibility · LIC 500 Personnel Report · LIC 400 Affidavit Regarding Client/Resident Cash Resources · LIC 610D Emergency Disaster Plan · LIC 9020 Register of Facility Residents · Copy of current Administrator's Certificate · Copy of Liability Insurance · Copy of current facility sketch · Copy of current Lease/Rental Agreement or Property Tax document showing control of property. Deficiencies cited (see LIC809-D page) from Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator, whose signature below confirms receipt of report. Due to printer issues, this report was emailed to Administrator. Appeal Rights Provided Exit interview conducted with Rafael Aquino Licensee/Administrator.