Facility Evaluation Report

On 6/10/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with House Manager Idell Ervin. Administrator was contacted and permission received to have staff complete the inspection and sign the report.

Facility staff was observed with face coverings. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Social distancing and cough etiquette postings observed in facility. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues.

Food supply was checked and appeared to be an adequate supply . All resident’s room toured and observed to be adequately furnished and lit. LPA toured bathrooms and observed Trash bins with lids and Hand washing signs. LPA observed shared resident’s beds to be at least 6 feet apart. LPA checked residents’ locked medications. 30-day PPE supplies were observed. At 12:15PM LPA observed Fire extinguisher was expired with a service date of 5/26/2021.

Staff records were reviewed for good health and infection control training. Two out of four residents’ records reviewed to have updated emergency contact information. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 6/17/2022: Current copy

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

309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610E),Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020. An exit interview was conducted with Staff. Report signed on-site by Administrator and printed copy provided with Appeal Rights.