Routine inspection·September 13, 2022

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Licensee, Evelyn Serrano. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. There are currently 5 residents in care. This facility is licensed for 6 non ambulatory residents, with hospice waiver approved for 3 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. 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, 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 to start logging daily monitoring and temperatures checked for residents and staff. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels and required hand washing postings. Covid-19 Mitigation plan was reviewed by Community Care Licensing department on 12/27/2021. Facility has also submitted their Infection Control plan, that will be part of their plan of Operation. Caregivers have completed PPE training and have not been N-95 Fit tested. In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. LPA consulted regarding facility having at least two days of perishable and more than one week of non-perishable foods and food items should meet any residents dietary restrictions as per Physicians orders. There were 4 fire Extinguisher found to be charged, 3 with no service tags and one purchased 6/1/2021. LPA went over requirements of yearly service for all extinguishers in the facility. Continue report see LIC809-C LPA requested facility to submit paperwork for a change in Administrator to LPA Canela by 9/20/2022. LPA went over reporting requirements. LPA also requested the following updated records to be submitted to Community Care Licensing by 10/2/2022 · 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 Lease/Rental Agreement or Property Tax document showing control of property. 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. Exit interview conducted with Evelyn Serrano. Appeal rights provided.