Facility Evaluation Report

On 10/6/21 at 9:43am, LPA Michael Bilger arrived at this facility unannounced to conduct an annual inspection visit. LPA met with the facility manager Shalimer Goulding and explain the purpose of the visit. Licensee Esther Javier gave permission for Shalimar Goulding to sign in her absence.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed adult residential facility with a current census of 5. Facility has 5 bedrooms. Three bedrooms are designated for residents. Two bedrooms are designated for staff. There are two bathrooms for resident use. There is a formal living room and a dining area off the kitchen. LPA also conducted the infection control domain tool.

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, COVID - 19 informational, and social distancing signs posted throughout the facility, on the front door, and back yard. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use.

Water temperature reads 105.4*F in the bathroom and room temperature reads 73*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 4/5/2021. Facility has an emergency food and water kit.

LPA reviewed facility staff files and interviewed facility manager. Facility manager is also a certified Administrator with certificate expiration date of 6/9/23 and lives on premises. {Cont. on 809C}