Routine inspection·March 4, 2022

Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by Licensee, Danilo Sy (DS). Administrator, Jayson Sy (JS) was contacted and arrived during the visit. The facility currently provides care for four (4) residents none of which with a diagnosis of dementia. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator and facility staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 5/10/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are securely stored under kitchen and bathroom sinks and in the garage. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Hot water measured between 108.5 and 110.8 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by residents. During the tour LPA found that two (2) staff (S1 & S2) had fingerprint background clearance but were not properly associated to the facility. LPA has copies of Background Check Clearance documentation for S1 & S2. Administrator to immediately contact appropriate Department agency and associate staff to facility. Continued onto LIC809-C Infection Control: Facility has submitted a mitigation program plan which has been approved. All staff and residents have been vaccinated with no reported or observed symptoms. Posters have been placed at the front door, and facility has a station at main entrance with a sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and residents are screened on a daily basis. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Civil Penalties are also being assessed in the amount of $200.00 due to two (2) staff not properly associated to the facility. Today's assessment of $100.00 for each staff is for violation of Title 22 Regulation # 88735(e)(2). Danilo Sy's Administrator Certificate 6024440740 is valid until 2/20/2023 Jayson Sy's Administrator Certificate 6042012740 is valid until 9/19/2022 Exit interview conducted with facility Licensee, whose signature on this document confirms receipt. A copy of the signed report was emailed to Licensee.