Facility Evaluation Report

This is an Amended report from an Original dated October 9, 2023**

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/9/23 at 4:20pm. LPA met with Arvin Mariano , House Manager/Caregiver and stated the purpose of the visit. The caregiver is fingerprint cleared and associated to the facility. Adora Ancheta, Licensee arrived within 15 minutes to assist with todays visit. The facility is licensed for a capacity of 6 residents of which 4 maybe non-ambulatory. LPA observed a Designation of Facility Responsibility (LIC308) for Arvin Mariano during this visit. The Administrator Certificate was observed for Kelly Ancheta which expired 5/18/23. LPA did not observe documentation of payment and hours for renewal. LPA observed P&I monies for Resident #1 (R1) which has been documented at $594.88 monies to be present. However, LPA and Arvin Mariano , House Manager/Caregiver counted the monies being held as 609.88 which is not commingled but not documented properly during this visit. LPA observed residents participating in group activities during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 71*F which is within the required range of 68-85*F. The hot water temperature was measured at 139.4 *F which is not within the required range of 105-120*F. LPA observed fire extinguisher(s), pull alarm system, smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed 2 staff files and 2 resident files and conducted interviews of staff during this visit.

Upon a file review the following items were discussed to be submitted with any changes annually:

Any addendums to the Infection Control Plan, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Affidavit Regarding Client/Resident Cash Resources (LIC400), Surety Bond (LIC402), Emergency Disaster Plan (LIC610E), Administrative Organization (LIC309), Control of Property

Per California Code of Regulations (CCRs) - Title 22, Division 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.