Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Zhenying (Jenny) Liu, direct caregiver. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.

Facility has a screening station with sign-in sheet, COVID-19 questionnaire and thermometer. Zhenying (Jenny) Liu took LPA's temperature upon arrival and screened for COVID symptoms. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff and client's temperatures are taken daily and documented. Staff clean and disinfects the facility on a daily basis. Facility has COVID-19 precaution postings and liquid hand soap available in the bathrooms. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing.

LPA discussed the following requirements with the facility staff:

· Facility to obtain N-95 mask fit testing (not training) for staff (Cal/OSHA requirement).

· Paper towels required to be available in bathrooms.

· Immediately notify Community Care Licensing (CCL) of any epidemic outbreaks/cases or incidents & submit a report.

LPA requested the following updated documents to be submitted to Community Care Licensing by 06/16/2022:

· LIC 308 Designation of Facility Responsibility · LIC 500 Personnel Report · LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash resources) · LIC 402 Surety Bond (if handling P&I for clients) · LIC 610D Emergency Disaster Plan · LIC 9020 Register of Facility 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 staff Jenny, whose signature on this document confirms receipt. ** Administrator was unavailable, LPA will return at later date to review additional items.

*No deficiencies cited during this inspection