Facility Evaluation Report

Licensing Program Analyst(s) Victoria Brown and Arvin Villanueva arrived unannounced to conduct an initial 10 day visit on 5/20/24 at 4pm on a subsequent visit. LPAs met with Rosa Elma Quiambao and stated the purpose of the visit. LPAs observed the following during this visit:

2 caregivers during the visit one of which was not finger print cleared an both are not associated to the facility.

LPAs observed medications on the counter and dining table in a 7-day pill box accessible to resident's.

LPAs observed the fire extinguisher on the wall that has an expiration date of 8/11/22.

LPAs did not observe a register of records for staff or residents during this visit.

Based on observation these deficiencies will be cited during this visit.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit.

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The facility representative was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, a copy of the report was given.