Facility Evaluation Report

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced plan of correction (POC) visit to follow up on deficiencies given on 5/23/24 during an annual visit. LPA met with John Lee and explained the reason for the reason.

On 5/23/24 LPA Flores conducted an unannounced annual visit at the facility and cited the following:

Type A - Section CCR - 80088(e)(1) Fixtures, Furniture, Equipment, and Supplies: On 5/3/24 water temperature tested at 122.1 in bathroom #1 (2nd floor). On 6/4/24 LPA Flores tested water temperature in the three bathrooms and tested between 109.3 - 111.2 degrees F., which is within the required 105-120 degrees F. Deficiency cleared as of 6/4/24.

Type B - Section - CCR - 85095.5(c) Infection Control Requirements: On 5/3/24 Infection Control Plan was not available for review. On 6/4/24 LPA Flores was provided a copy of Infection Control Plan and meets the requirements for new Title 22 Regulations. Deficiency cleared as of 6/4/24.

Type B - Section - CCR - 80088(b) Fixtures, Furniture, Equipment, and Supplies: On 5/3/24 screen in the screen door exiting to the balcony was ripped. On 6/4/24 LPA Flores observed the screen door was removed as it is not needed in the balcony. Deficiency cleared as of 6/4/24.

Evacuation chairs have been order and waiting for delivery. HIV/TB training was conducted on 6/3/24. Emergency Drill was conducted on 5/24/24.

Exit interview was conducted with John Lee and a copy of this report and clearance letters were provided.