Facility Evaluation Report

Licensing Program Analyst (LPA) Cassandra Mikkelson and Licensing Program Manager (LPM) arrived unannounced and met with Licensee Joel Siesa to conduct an annual inspection utilizing the inspection tool.

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed two (2) resident rooms, common area bathrooms, kitchen, common areas and perimeter of care facility.

LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed two (2) resident files, one (1) staff file and two (2) resident medications.

Facility has a current copy of certificate of liability insurance and LPA requested a copy.

As a result of this visit, deficiencies were cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiencies are listed on 809-D pages.

Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents. LPA gave a copy of LIC311C to Licensee for review to ensure all documents are correct in client charts.