Facility Evaluation Report

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/14/23 at 2:45pm. LPA met with Peter Batingal , Caregiver who left a message for Eliodoro Penas Jr., Administrator regarding todays visit. The caregiver is fingerprint cleared and associated to the facility.

The facility is licensed for a capacity of 3 non-ambulatory residents. LPA observed a Designation of Facility Responsibility (LIC308) for Eliodoro Penas Jr. during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 111.4 *F which is 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. Staff and residents files are unavailable for review. LPA observed P&I monies for Residents are unavailable for review. LPA observed 2-day perishables and an abundance of meat items in 7-day non-perishables. However, fruit and vegetables are not present.

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 (LIC610D), Administrative Organization (LIC309), Control of Property

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 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.