Facility Evaluation Report

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator Monica Kim and the purpose of the visit was explained. The following 12 (CARE) tool domains were utilized during the inspection:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was observed

The facility is a single-story home: Total of (9) bedrooms of which #1-#6 is for residents only and #7-#9 are staff rooms and office spaces, (3) bathrooms, dining room, (2) living rooms, backyard with locked detached garage, and a laundry area. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard.

Water temperature readings measured within title 22 regulations.

A current Plan of Operation observed. Dementia Care Plan Observed

A fire clearance for 6 residents of which (6) may be non ambulatory and up to three (3) bedridden

Hospice care waiver approved for up to six (6) residents.

Facility has an active liability insurance. Copy was collected and reviewed

Administrator on file is current. Administrator certificate is currently active

Five (5) staff files were reviewed. Required documents observed for files reviewed.