Facility Evaluation Report

On 5/2/22 at 9:00 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. Administrator Stacyrae Seares arrived a short time later. Five staff and five residents were present during the inspection.

A tour of the facility was conducted. COVID-19 guidelines are in place. Facility has one entrance/exit point for visitors and a separate entry point for residents/staff. Facility was observed clean and without any obstructions. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and no residents share a room. All hoyer lifts observed operational. LPA observed med cart and excess supply of meds. Food supply observed sufficient. Cleaning and PPE supplies were observed sufficient. Staff records were reviewed for good health. Residents files have updated emergency contact information. Administrator certification is expired as of 3/29/22, but has an application for recertification pending.

The following updated forms are to be submitted to CCL within 2 weeks:

LIC500, LIC400, LIC402, LIC610D (new revision)

1. Hot water in west bathroom measured at 125.3 degrees F.

Deficiencies is being cited based on LPA observation conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

Exit interview conducted. A copy of this report and appeal rights were given to Administrator Stacyrae Seares, whose signature confirms receipt of this report.