Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Wallace arrived at this facility unannounced to conduct an Required 1 Year Annual Inspection Visit. LPA was met by care staff and Administrator showed up later. LPA explained the purpose of the visit.

LPA and care staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 5. There are three client bedrooms and two client bathrooms. The hallway has COVID-19 precautions in place including social distancing noted. Medications and toxins noted to be locked to residents in care. LPA also conducted the infection control domain tool. Water temperature reads 113.9*F in the kitchen and room temperature reads 74*F. LPA observed the facility to have adequate food supply. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was checked 6/7/2022. Facility has an emergency food and water kit. The facility submitted a LIC 808 mitigation plan , which was approved. The facility has central entry point and has implemented screening and sign in procedures at the front door area. The facility conducts routine symptom screening for employees, residents, and visitors. LPA observed the facility to have hand washing stations, COVID-19 informational signage, and social distancing signs posted throughout the facility, on the front door, and outside. The facility has a designated infection control lead individual. The facility is able to designate and dedicated a COVID-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2-days perishables in place. Resident rooms were sanitary and had the required furniture and furnishing.

LPA reviewed three (3) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required.

LPA reviewed two (2) resident facility files and all documents were in files required by Community Care Licensing (CCL).

LPA requested the following documents to be submitted via email by October 26, 2022: LIC 308, LIC 400, LIC 610D, Facility Program/Plan of Operation, and Surety Bond.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was held and a report with appeal rights was given to Administrator.