Routine inspection·July 9, 2021

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced visit on this day for the purpose of conducting a Required - 1 Year Annual. LPA explained purpose of visit with Caregiver Mark Toole. Administrator (AD) Georgia Wilcomb was notified of the visit by CG and arrived at approximately 9:15 AM to finish visit with LPA. LPA reviewed five resident files. LPA reviewed admission's agreements, medical assessments, TB and appraisals. LPA requested to review 3 staff files. LPA verified criminal record clearances. LPA reviewed training records, All staff have current CPR/First Aid/AED certificates. LPA toured the facility with Administrator. Fire extinguishers were mounted and charged with the last service date of 3/22/2022. LPA reviewed food services. There was enough food on hand to meet the 2 day perishable and 7 day non-perishable requirement. Bathrooms and hand washing areas were observed clean and sanitary. There is a back wall in northwest end bathroom that needs to be replaced behind the toilet. Dry rot and LPA's foot went through the wall down near bottom of the wall near shower. Non-slip mats were observed in shower. Hot water temperature was measured in 2 of 2 resident bathrooms. Water temperature was recorded at 107.3 and 111 degrees F. All toxins were not stored inaccessible to residents in care. The facility was at a comfortable temperature for residents in care. Medications were observed centrally stored and inaccessible. Continued on 809-C Page 2 Continued from 809 - Page 2 In order to keep the facility file current please provide the following documentation to CCL by 7/23/2021: LIC 308 - Designation of Administrator, LIC 400 - Affidavit Regarding Cash, LIC 500 - Personnel Summary, LIC 610-E Emergency Disaster Plan, and Current Administrator Certificate. The following deficiencies were cited on 809-D per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrator and a copy of this report along with appeal rights provided.