Facility Evaluation Report

Licensing Program Analyst (LPA) Bruce Jacobs arrived to conduct an unannounced Annual inspection on this date. LPA met with Facility Administrator Maryam Faall and Jane Mofor. They were informed of the purpose of the visit and assisted with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. The facility has submitted a program design to the Regional Center and is in the process of being vendorized for a VMRC home. tTe facility will submit the approved program design to Licensing. Administrator's Certificate for Maryam is 6047363735, expires 6/12/22.

LPA toured the facility and reviewed the Mitigation Plan as well as discussing Personnel Policies, Abuse Reporting Procedures, In-Service Training and Medication Procedures during the Post-Licensing Inspection. Smoke alarms were tested and were operable. Fire extinguisher was serviced in November 2021 and is in compliance. The facility has 4 client bedrooms and 2 Client bathrooms. Water was tested at 115.8 degrees. Physical plant deficiencies issued on the attached 9099D.

LPA observed the following posted in the facility: See Something Say Something complaint poster, Reporting Requirements per AB40, Resident Bill of rights, Resident Personal Rights, Evacuation Routes and facility license were all posted as required. LIC 500, LIC 308, and LIC 309 were requested to be submitted to Licensing within 30 days as needed.

Exit interview held with acting Administrator and a copy of report given at the conclusion of the visit.