Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Francis Fernandez, backup-Administrator . The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. LPA conducted a tour of the facility, all exits were unobstructed, medication was centrally stored, food supply per regulation, client P&I funds were not commingled. The facility has a screening station (hand sanitizer, thermometer, COVID questionnaire, and a sign-in sheet for visitors and staff). LPA was screened for COVID-19 symptoms and temperature was taken and documented. Staff and client's temperatures are taken and documented daily . LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. Facility staff have completed required training. N-95 respirator Fit testing for staff (Cal/OSHA requirement) is in process, Administrator purchased a test kit for staff . LPA observed a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns. All staff wore a face mask during this visit. LPA verified staff's vaccination status for COVID-19; staff have completed and have documentation in their files.

LPA requested the following updated forms to be submitted to Community Care Licensing by 10/27/2022:

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

· LIC 400 Affidavit Regarding Client/Resident Cash Resources

· 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 back-up Administrator, whose signature on this document confirms receipt.

Due to issues with printer, this report was emailed to Administrator. **No deficiencies cited during this inspection