Facility Evaluation Report

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management for Legal/Non-compliance inspection visit. LPA Rai met with Licensee/Administrator Xiuyan Chen and stated the purpose of today's visit. LPA observed 4 residents and 2 staff (including Administrator) at the facility.

The purpose of the visit is to ensure that facility is adhering to the Compliance Plan submitted to Community Care Licensing (CCL) after a Non-Compliance Conference held on 3/28/2023. LPA reviewed facility files pertaining to the Corrective Action Training Plan created in response to the Non-Compliance Conference.

LPA observed the facility to include kitchen, dining room, living room and exterior perimeters. Knives, medications and chemicals were observed locked. Supplies of drinking water, two days perishable food supplies and seven days nonperishable food supplies were observed sufficient. No chemical were observed in the cabinet with food supplies.

The facility was maintained and kept organized. The facility cleaning supplies and chemicals were kept in a separate storage that is locked and not accessible to resident. LPA Rai reviewed the 2 residents records to include but not limited to Admission Agreement, Physician's Report, Appraisal Needs and Services Plan, Centrally Stored Medication Record and Personal Rights. LPA Rai reviewed 1 staff record and observed record to be complete and updated.

No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Licensee/Administrator Xiuyan Chen and a copy of the report was provided.