Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Imelda Padama, Licensee. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. LPA toured the facility and observed 6 residents in care. Facility has a COVID-19 screening station (visitor sign-in sheet, COVID questionnaire, thermometer, hand sanitizer). LPA reviewed records and conducted a spot check of resident medication. Fire extinguisher was charged and and serviced 03/15/2022. The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, and surgical masks. Staff and Resident's temperatures are taken daily and documented. Staff clean and disinfect the facility throughout the day. LPA observed COVID-19 precaution postings; grab bars, non-slip mat, liquid hand soap and paper towels available in bathrooms. During this visit, LPA verified staff vaccination records for COVID-19.

LPA discussed the following requirements with Imelda Padama:

· Facility to obtain N-95 mask fit testing for staff (Cal/OSHA requirement) - Technical Advisory Note was issued to the facility during this visit.

LPA requested the following updated forms to be submitted to Community Care Licensing by 07/13/2022:

1) LIC 308 Designation of Facility Responsibility (1 person per form); 2) LIC 500 Personnel Report; 3 ) LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents); 4) Copy of Liability Insurance; 5) LIC 610E Emergency Disaster Plan; 6) LIC 9020 Register of Facility Residents; 7) Copy of current Administrator's Certificate; 8) Copy of current Lease/Rental Agreement or Property Tax document showing control of property;

Reminder: Facility Infection Control Plan due 06/30/2022 Report continued on LIC 809-D...