Facility Evaluation Report

At 2:20 p.m. on this day, March 1, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on February 14, 2024. LPA was granted entry by staff, Dzul Iscandari, and informed the reason for visit. Kiptiatu Iscandari, licensee, arrived at around 2:45 p.m.. Mohamed Conte, administrator, arrived at 4:30 p.m.

LPA reviewed 5 staff and 3 residents records, and interviewed 2 staff and 2 residents. Medications checked, and compared with LIC622 Centrally Stored Medication and Destruction Record, and doctor's orders. Residents' P&I checked and compared with last recorded balance.

-at 2:55 p.m., staff's (S2 and S3) First Aid certificates expired 12/05/23.

-at 3:00 p.m.. S3 has no TB test on file.

-at 3:30 p.m., residents' (R2 & R3) Appraisal/Needs and Services Plan were outdated.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of correction by plan of correction due date. and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of correction were discussed with the administrator and licensee.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.