Facility Evaluation Report

Licensing Program Analyst (LPA) Hannah Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by and discussed the purpose of the visit to Staff Ma Christina Rosal. The facility's license shows a maximum capacity of six (6) non-ambulatory residents. Hospice waiver for three. During today’s inspection there were three (3) residents in care.

LPA with staff toured the interior and exterior of the facility and inspected each room. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. LPA observed Resident #1 (R1) to have a trash can in their bedroom without a tight-fitting cover that contained used gloves. Also, LPA observed Bathroom #2 (B2) to have a trash can without a tight-fitting cover that contained used gloves. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water exist on the premises. Per Staff Rosal, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas.

One (1) deficiency was cited per California Code of Regulation, Title 22. A plan of correction was jointly formulated, and an exit interview was conducted with Staff Rosal whom a copy of this report, LIC809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.