Facility Evaluation Report

On 5/4/2023, Licensing Program Analyst (LPA) K. Kaur arrived unannounced at the above facility to conduct

an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff Justin Fielding. House supervisor Ravi (Tony) Peiris and Administrator Lori Wyatt was contacted and would be arriving shortly.

All pathways, entrances and exits were clear from obstructions. LPA and Administrator began the tour at the facility kitchen. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Tour continued to the living room. At 12:30 LPA observed the living room carpet to have spills and was mated in areas. Tour continued to Residents Rooms. LPA toured three shared bedrooms which were observed to be furnished with required furniture and adequate lighting. Fire extinguisher in hallway was last serviced on 1/17/2023 and was fully charged. Linen supply is kept in the laundry room. Cleaning supplies and chemicals are kept locked in staff office. Medications are kept in the Kitchen cabinet. Resident's records contained signed Admission Agreement, Personal Rights, and current Physician's Report. Staff files were reviewed for good health. Staff files had First Aid training. LPA observed sufficient seating under covered patio area in the back of the facility.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22,

LPA is requesting the following documents be submitted to the Fresno CCL office by 5/25/2023: Current copy

of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization

(LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan

(LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

Exit interview was conducted. Report signed on-site; printed copy of report provided with appeal rights.