Facility Evaluation Report

Licensing Program Analysts (LPA's) Ruth Wallace and Kesha Lewis arrived at the care home to conduct an unannounced Required 1 Year Annual Inspection Visit. Facility Administrator was informed of the purpose of the visit and was able to assist with the completion of the inspection focusing on the facility's mitigation plan and infection control procedures. The facility has submitted a written mitigation plan (LIC 808) and LPA's obtained a copy for the Plan on this visit for review. Administrator Certificate for #602456735 Expires 3/24/22023.

LPA's and Administrator toured the facility and reviewed the Mitigation Plan as well as discussing Personnel Policies, Reporting Procedures, Training Procedures during the Inspection. Smoke alarms and smoke detectors are hard wired to the facility, were tested are operational. Fire Extinguishers are current and were inspected 11/2/2021. The hot water temperature was measured using the facilities thermometer to be 108.4*F which is within the required range of 105-120*F. Medication and toxins were locked and facility was determined to have an adequate food supply. The interior and outdoor area of the home was inspected including bedrooms, kitchen, bathrooms, and common areas for this home. There are three clients in the home and three client bedrooms. Two caregivers were present at the time of the inspection.

LPA's observed the following posted in the facility: Hand washing and visitation policies, See Something Say Something complaint poster, and visitation signs. Resident Personal Rights, Evacuation Routes and facility license were all posted as required. Current LIC 500, LIC 308, and LIC 309 were requested to be submitted to Licensing within 30 days.

A review of (4) facility resident records was conducted and have all required documents for Community Care Licensing (CCL). A review of (3) facility personnel records was conducted. All staff is fingerprint cleared and associated to the facility. All staff have current First Aid/CPR certifications on file. Facility is conducting initial and continuing training as required.

Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 6, there were no deficiencies cited during this visit.

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