Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced Required 1 Year Annual Inspection Visit. LPA met Direct Care staff and explained purpose of visit focusing on the facility's mitigation plan and infection control procedures. Administrator Esther Gapasin (Certificate # 6010498735 Expires 1/12/24). Facility has submitted a written mitigation plan (LIC 808) and LPA reviewed the plan for this infection control inspection. LPA and direct care staff toured the facility and reviewed the Mitigation Plan that has been submitted and is under review as well as discussing COVID Training Procedures during the Inspection.

Smoke alarms and smoke detectors are hard wired to the facility, were tested are operational. Fire extinguishers were serviced in 4/4/2022 and are in compliance. Facility has carbon monoxide detectors. Facility has a sprinkler systems. Medications were locked and facility was determined to have an adequate food supply. Facility's PPE supplies were determined to be adequate for a 30 day supply. The interior and outdoor area of the home was inspected including bedrooms, kitchen, bathrooms, and common areas for this home. There are five clients in the home and 4 client bedrooms. One care staff was present when LPA arrived for 5 clients with 3 bedrooms and 3 bathrooms.. Water temperature was tested at 108.4 degrees F. which is within the required range of 105 to 120 degrees.

LPA reviewed resident and 4 staff files, including criminal record clearances.

All staff today are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. LPA was able to verify last documented fire drill was on 6/15/2022.

LPA requested updated copies of the following documents to be submitted via email by 9/22/22:

LIC 308 Designation of Facility Responsibility, LIC 400 Affidavit Regarding Client Cash Resources, LIC 402 Surety Bond, LIC 500 Personnel Report, and Plan of Operation/Facility Program

LPA observed the following posted in the facility: Hand washing and visitation policies, Visitation signs are posted outside the home. Resident Personal Rights, Evacuation Routes and facility license were all posted as required.

Per California Code of Regulations, Title 22 Division 6, Chapter 8 and Health and Safety Code, One deficiency was observed, see 809-D. Exit interview held with direct care staff and copies of reports and appeal rights were given at the conclusion of the inspection.