Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/15/23 at 1:30PM to conduct a Required - 1 Year inspection visit. LPA met with Deirdre Pinheiro, Caregiver, Clifford G. Tejada, Administrator, Carmenchita Tejada, Licensee and explained the purpose of the visit. Licensing fees are current. The Administrator certificate for Clifford G. Tejada expired 6/3/23 but LPA observed documentation that the renewal has been submitted with fees to Community Care Licensing.(CCL) timely.

The facility is licensed for a capacity of 6 residents. LPA observed residents are at day program during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the facility is handling P&I monies for residents which are not commingled. P&I for resident #1 (R1) is documented and counted as exact and correct during this visit. Facility has a Infection Control Plan on file. The temperature inside the facility was observed to be at 69*F which is within the required range of 68-85*F. The hot water temperature was measured at 105.9*F which is within the required range of 105-120*F. LPA observed a pull alarm system with sensors, 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. Upon a file review the following items were discussed to be submitted with any changes annually:

Designation of Facility Responsibility (LIC308), Personnel Report (LIC500), Administrator Certificate-Updated, Affidavit Regarding Client/Resident Cash Resources (LIC400), Surety Bond (LIC402), Emergency Disaster Plan (LIC610E), any addendums or updates to Infection Control Plan.

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