Facility Evaluation Report

Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Valentine Calero, caregiver. Eliza Pangan-Kloster, Administrator later arrived and joined the visit. LPA met with Administrator Pangan-Kloster and discussed the purpose of today’s visit.

A tour of the facility was conducted inside and out. LPA accompanied by Valentine Calero, caregiver conducted a general overall inspection, with specific focus on infection control protocols.

During today's inspection LPA observations include the following: Symptom screening procedures for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing/hand hygiene practices, cough and sneeze etiquette and other infection control procedures; testing plan and procedures for staff and clients; plans for containing infections, PPE supplies procedures and training; and disinfection procedures.

LPA provided updated guidance with current PINs for Resident Cohorting, Isolation and Quarantine, Staffing and Use of Personal Protective Equipment Based on Resident Coronavirus Disease 2019 (COVID-19) Status; Best Practices for Visitation Related to Coronavirus Disease 2019 (COVID-19) and the Recession of the Statewide Visitation Waiver; Updated Adult and Senior Care Facility Worker Coronavirus Disease 2019 (COVID-19) Vaccination, Booster, and Testing Information; and Coronavirus 2019 (COVID-19) Vaccine Additional and Booster Doses.

Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Administrator Eliza Pangan-Kloster. A copy of this report, along with the Licensee Rights (3/22) was provided to Administrator Pangan-Kloster at the conclusion of the visit. The signature below serves as confirmation of receipt of these documents.

LPA requested for Administrator Pangan-Kloster to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-D to the licensing office within 10 business days. Forms available at www.ccld.ca.gov .