Facility Evaluation Report

Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a health and safety check on the residents at the facility. LPA was greeted and granted entry by staff and explained the reason for the visit. LPA toured the facility. LPA observed resident rooms have the required furnishings. LPA observed resident rooms are clean and organized. LPA observed resident bathrooms are clean and operational. Hot water measured at 114.6 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed sufficient perishable and non-perishable food in the kitchen. LPA observed utilities on and operational. LPA observed six residents in the dining room having breakfast. Interviews with one out of two staff stated they are owed back pay.

LPA observed notification of the proceedings to revoke the license posted at the facility for review.

Resident 1 (R1)'s file did not contain a signed admission agreement, a signed personal rights document (LIC613C), incomplete information on the identification page (LIC601), and incomplete information and missing licensee/administrator signature on R1's appraisal (LIC603A).

One out of two staff did not have evidence of a health screening, TB test, personnel record, and required training.

Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A civil penalty is being assessed for a repeat violation. This report was discussed with the facility representative and a copy was provided along with appeal rights.