Facility Evaluation Report

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required annual inspection visit. LPA met with Administrator and explained purpose of visit. Administrator's Certification expires 11/17/2023. There are currently three residents who reside at this home.

LPA and administrator inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, activity rooms, medication storage, kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for two day perishable and seven day nonperishable.

Fire extinguisher was last inspected April 13, 2023. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 112.4 F degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA confirmed all staff present is background cleared.

LPA reviewed three staff and two resident files. Resident emergency contact complete. LPA observed all staff and resident files complete. All staff have criminal record clearance and are associated to the facility.

There were no deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.

LPA received the following updated documents : LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, and copy of current Administrator’s Certificate.

Exit interview conducted with Administrator. A copy of report and LIC 811 (Confidential Names) left at facility