Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Higinia Alvis, Administrator; Alejandra Arciga, Direct Support Professional was also present . The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.

LPA toured the facility, all exits were unobstructed. Facility has a COVID-19 screening station (visitor sign-in sheet, COVID questionnaire, thermometer, hand sanitizer). Fire extinguisher was charged and serviced 05/17/2022. The facility has an supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. The facility has submitted their Infection Control Plan to the California Department of Social Services, Community Care Licensing. Staff have received refresher training on Proper Utilization of PPE, Infection Prevention & Control, and Environmental Cleaning to Prevent COVID-19 and other Infectious Diseases from Solano County Public Health on 01/11/2022 . Staff have current CPR/first aid certifications in file. During this visit, LPA verified staff COVID-19 vaccination records. LPA verified documentation on N-95 Respirator FIT testing for designated staff (Cal/OSHA requirement) was completed. All staff wore face masks during this visit.

LPA requested the following updated forms to be submitted to Community Care Licensing by 11/21/2022:

· LIC 308 Designation of Facility Responsibility (1 person per form)

· LIC 400 Affidavit Regarding Resident Cash Resources (indicate if not handling cash for residents)

· LIC 9020 Register of Facility Residents/clients

· Copy of current Administrator's Certificate

· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

Exit interview conducted with Administrator, whose signature on this document confirms receipt. **No deficiencies cited during this inspection