Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection. LPA was greeted by Rongmiu (Susan) Xu , DSP . Licensee and Administrator Guolian (Mark) Zhang arrived later.

LPA toured the facility and observed all exits were unobstructed. Fire extinguisher was charged and serviced 04/28/2022.

There are 6 smoke detectors & 1 carbon monoxide detector, which were tested & observed operational. LPA reviewed client and staff files. LPA observed medication to be centrally stored. Staff wore masks during this visit.

LPA requested the following updated forms to be submitted to Community Care Licensing by 04/20/2023:

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

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

· LIC 9020 Register of Facility Residents

· Copy of current Administrator's Certificate

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

Exit interview conducted with Guolian (Mark) Zhang , Administrator, whose signature on this document confirms receipt. No deficiencies cited during today's visit.