Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual inspection Visit. LPA introduced herself, explained the purpose of the visit, and was met by Administrator. LPA was screened for COVID-19 symptoms with temperature prior to being allowed inside the facility. Administrator confirmed staff have not displayed any signs or symptoms of COVID-19 in the last 10 days.

LPA and administrator toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA reviewed and approved the LIC 808 mitigation plan during the visit. The facility backyard has a pool surrounded by a locked fence. LPA observed the facility to have COVID-19 informational and hand washing signs posted at the front door and throughout the facility. Facility has a 30 day supply of PPE. LPA observed the temperature inside the facility was measured at 74*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 115.4*F. Facility has a place for nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area, cleaning supplies, and staff files to be locked. Resident rooms was sanitary and had the required furniture and furnishings. Resident bathrooms observed to have non-skid mats, soap, paper towels, and closed lid garbage cans. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were last inspected on 12/14/2022. Emergency disaster plan and necessary signage posted and available. First aid kits and emergency supply of food were observed to be fully stocked. LPA observed no obstruction of emergency exits inside or outside of facility.

LPA reviewed two (2) staff records and three (3) client records. All files were complete. Staff are fingerprint cleared and first aid certified. LPA observed the medication and the MARS sheets. Medications appear to be documented appropriately.

LPA requested the following documents to be submitted via email by January 11, 2023: Administrator Certificate, Copy of Deed, LIC 308 - Designation of Administrator Responsibility, LIC 610-D, and LIC 500 Personnel Summary

Per California Code of Regulations, no deficiencies were observed during this visit.

An exit interview was held with administrator and a copy of the report was left at the facility .