Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Margaret Mroz, Administrator & Licensee. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility.

LPA conducted a walk-through of the facility and all exits were observed unobstructed. Facility has a screening station with sign-in sheet and COVID-19 questionnaire. Administrator screened LPA for symptoms and took LPA's temperature upon arrival. Administrator has a current CPR/first aid certification. Fire extinguisher was charged and serviced 03/01/2022.

The facility has a supply of PPE including gloves, hand sanitizer, N-95 respirators, gowns, face shields, COVID-19 test kits, and surgical masks. Staff have received training on the following topics: infection prevention, symptoms, transmission and PPE use. Staff and client's temperatures are taken daily and documented. Administrator cleans and disinfects the facility on a daily basis. 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. Licensee has submitted the facility's Infection Control Plan, which is pending review. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. LPA discussed the following requirements with Licensee: Obtain N-95 mask fit testing for staff (Cal/OSHA requirement).

LPA requested the following updated records 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); · LIC 402 Surety Bond; · 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 Licensee/Administrator Margaret Mroz, whose signature on this document confirms receipt. *No deficiencies cited during this inspection