Routine inspection·July 22, 2021

Licensing Program Analyst (LPA) Katrina Walters conducted an unannounced Annual Required – 1 year Infection Control inspection visit to this facility and was greeted by Staff, Prima Eudelyn Rabana (PER). The Administrator, Rosalina Lubuguin (6010923740 exp. 2/09/2022) was not available for today's visit . A risk assessment was done prior to entry. At the time of inspection there were two staff providing care and supervision for four residents. The inspection is focused on the Infection Control procedures and practices of this facility. This facility has submitted a COVID-19 mitigation plan to Community Care Licensing, that was approved on 7/22/21. LPA observed that the facility is following the following mitigation plan policies: Upon entry, LPA was signed into the facility sign-in sheet and had temperature checked and logged into a binder. LPA advised that the screening questions be added to the sign in sheet. Resident's temperatures are logged in a separate binder. There was one entry point for the facility. LPA toured the facility with staff. Signs were posted throughout the facility to promote social distancing and hand washing. During facility tour the facility was found to be clean and at a comfortable temperature. Alcohol based hand wash was available in each client's room and throughout the facility. Continued on 809 C Continued from 809 Facility has Personal Protective Equipment (PPE) stored in a spare bedroom. Clients’ medications are stored in a locked cabinet in the dinning room. Facility has at least 30-day supply of medication for clients based on pharmacy supply and refill practices. During inspection, LPA also observed three sets of medication pre-poured in plastic cups. (pictures taken). LPA confirmed the medication was for their PM 7/22, AM 7/23 and PM 7/23. LPA explained regulations regarding pre-pouring medications. This violation to regulation is being cited on LIC 809-D. LPA is requesting that the Administrator sends the following updated forms to Community Care Licensing attention LPA Walters 7/30/21: Updated Personnel Report (LIC 500) and an Updated Emergency Disaster Plan (LIC 610 E). California Code of Regulations, (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC- 809D. Exit interview conducted with Staff, Appeal Rights provided. The signature below confirms receipt.