Facility Evaluation Report

Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with staff and was later joined by Administrator and Licensee Angela Zhang who were informed of the purpose of the visit. At the time of the visit there was (3) staff and (5) residents present.

The facility is a one story home with (4) bedrooms and (2) bathrooms for residents and (1) staff bedroom. No pools or firearms are being kept at the facility. LPA observed the following:

Infection Control: The LPA observed the facility restrooms and kitchen had hand hygiene supplies. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA did not have an infection control plan at the time of the visit, there a citation is being issued.

Physical Plant: LPA observed the resident bedrooms. Physical plant, floors, windows, and doors were observed and fixtures and furniture were in good were present. The outdoor area was observed to be free of hazards. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational. The hot water temperature was initially read at 110F in a resident restroom. Based on record review Resident #2 (R2) is bedridden and the licensee is approved for non-ambulatory residents only. LPA observed R1's room does only has (1) exit and does not have a side door leading to the emergency route. Therefore, the licensee is being cited for not having the appropriate fire clearance.