Facility Evaluation Report

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Zosima Rillera.

During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks were 105 F and 106 F. LPA tested the smoke detectors in three out of three resident rooms and in the hallways and each smoke detector functioned properly when tested. Each bedroom had working lights and available bedding and clothing storage areas. LPA toured the outside of the facility and found it to be clear of obstructions. LPA Marrufo reviewed the first aid kit and found it to be complete.

LPA reviewed five out of five resident records and found them to be complete. LPA reviewed five out of five resident Centrally Stored Medication and Destruction Records (CSMDRs). Resident R1 had two medications missing from the CSMDR and resident R2 had one medication missing from the CSMDR. LPA reviewed four staff records. Staff S1 was missing a current first aid certification. Staff S2 was missing an LIC503 Health Screening Form.

Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. A civil penalty of $250 was issued due to a repeated deficiency. This report was reviewed with Administrator Zosima Rillera and a copy of this report and appeal rights were provided.