Routine inspection·October 5, 2022

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:14AM. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with facility staff and discussed the reason for the visit. Licensee Representatives/Administrators Grace and Teddy Catabay arrived at 10:35AM. Entrance interview conducted. The LPA, along with facility Licensee Representative Grace Catabay, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Fire Extinguisher was observed to be fully charged and purchased on 11/24/2021. Hardwired smoke detectors and separate carbon monoxide detector were tested at 10:49AM and were functional at the time of the visit. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. LPA observed the fireplace in the living room, which was adequately screened. The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. The facility laundry room and garage were observed to be locked. The outdoor shed was locked and contained the emergency water, PPE supply, and storage. KITCHEN : Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency supply. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Report Continued on LIC 809-C (Continued from LIC 809) BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are for resident use and 1 (one) is designated as a staff room. RESTROOMS: The LPA observed 3 restrooms in the facility; 2 (two) are designated for resident use and one is a staff restroom. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in both resident restrooms and measured at 139.0 degrees Fahrenheit at 10:44AM in the shared resident restroom and after adjusting the water heater, measured at 131.8 degrees Fahrenheit at 12:03PM in the same restroom and 122.6 degrees Fahrenheit at 12:08PM in the private resident restroom. INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee Representative/Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff and visitors to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. The following recommendations were made: - N95 fit testing for all staff Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted with Grace Catabay. Today’s reports and appeal rights were reviewed and provided via email.