Facility Evaluation Report

LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 8 client bedrooms and 5 full and one half bathroom, kitchen, living, and dining rooms; there is no staff room. There is an enclosed backyard and detached 2-car garage, which is used for storage. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is inspected. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 9 residents present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Annie De La Cruz is a certified RCFE administrator (x 11/21) that oversees facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 11/24/21:

• Proof of high school graduation or college of administrator designee

• LIC 400 Affidavit Regarding Client Cash Resources

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. See Technical Advisory Notes for additional information.