Routine inspection·June 21, 2022

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, assistant Administrator, Renato Yamat. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. There are currently 3 residents in care, none receiving Hospice services. This facility is licensed for a total of 6 residents, with a hospice waiver to allow all 6 residents on Hospice services and no approval for bedridden residents/rooms. LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas to promote hand washing. LPA requested staff to screen LPA for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility, but LPA noticed some visitors are not being screened, and/or lacked temperature documentation. Infection control practices that are present: 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 submitted to the department on 7/21/2021. Caregivers have completed PPE training but have not been N-95 Fit tested. Facility had just conducted their food shopping and has at least two days of perishable and one week of non-perishable foods. Fire Extinguisher was found to be charged and serviced 1/2022. Facility staff to get N95 fit tested. LPA reminded facility gates have to be secured at the bottom of all stairs. LPA requested facility to remove any extra furniture stored in the side yard. Continue report see LIC809-C LPA requested the following updated records to be submitted to Community Care Licensing by 7/15/2022 · 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 Renato Yamat. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights provided.