Facility Evaluation Report

Licensing Program Analyst (LPA) Vasallo conducted an annual required visit. LPA met with caregiver, Berliani Simamora and explained the reason for the visit. Administrator, Indi Bhavsar was called and notified of the visit. LPA used the infection control tool to evaluate the facility. LPA observed the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed staff and resident files.

All 3 client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured. Bathrooms have the required hygiene items. The hot water was 104.6 degrees which is within the required 105 - 120 degrees. Cleaning supplies and chemicals are locked in the staff office. The office also contains all the PPEs. Facility has at least a 30-day supply of PPE. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are cleaning and working properly. There is additional food in the second refrigerator in the office. The common areas such as living room and dining room are clean and have the required furniture. The backyard has a shaded area and sitting area. Signs are posted throughout the home to remind staff and residents to wear masks and wash hands. Staff were observed checking visitor's temperature at the time of entry.

LPA reviewed resident files to confirm emergency contacts have been updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed 5 residents' medications. Medications are documented and stored properly.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to caregiver.