Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 11/13/23 at 9:15am. LPA met with Mary Ann Ortega , Caregiver and Cherry Madamba and stated the purpose of the visit. The Administrator Certificate expired on 6/29/2023. LPA was presented with a copy of the ACS Applications Pending List which confirmed Administrator has submitted pertinent documents and payment prior to due date. Licensing fees are current. LPA observed a copy of the Liability Insurance with an aggregate of 3,000,000 which expires 6/1/2024. LPA observed documented and counted monies for resident #1 (R1) which was not commingled to be in the correct amount during this visit. The facility is licensed for a total capacity of 6 residents. Upon arrival 3 residents were at day program and 1 was present involved with their individual activities. Facility has a Restricted Health Conditions Care Plan and Infection Control Plan on file. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The most recent emergency drill was conducted on 10/21/23. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 70*F which is within the required range of 68-85*F. The hot water temperature was measured at 106.5*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.

LPA observed 1 resident and 1 staff files and conducted interviews during this visit.

Upon a file review the following documents are discussed to be submitted annually with any changes: Personnel Report (LIC500), Designation of Administrative Responsibility (LIC308), Affidavit Regarding Client/Resident Cash resources (LIC400), Surety Bond (LIC402), Administrator Certificate-updated, Control of Property, Emergency Disaster Plan (LIC610E), Any addendums to the Infection Control Plan.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies observed or cited. Exit interview held, copy of report given.