Facility Evaluation Report

Licensing Program Analyst(LPA) Sarah Hurt conducted an unannounced visit today for the facility’s annual inspection. LPA met with Facility Staff Siauro Katoa There are currently 4 residents who reside at this home and there is 0 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 111 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA Hurt reviewed 3 facility staff files, and 3 facility resident files.

LPA Hurt observed facility trash bins with no lids. LPA Hurt observed this facility does have an Infection Control Plan but it is not on the LIC9282. LPA observed this facility does have an Emergency Disaster Plan but it is not on the current required LIC610D form. The facility does not currently have an Administrator.

The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Facility staff, Siauro Katoa and copy of report left at facility