Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Regyna Jackson-Branchcomb, 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 which with Administrator; all exits were unobstructed. The facility has a screening station (hand sanitizer, a thermometer, COVID questionnaire, and a sign-in sheet for visitors and staff). LPA was screened for COVID-19 symptoms and temperature was taken. The facility has a designated visitation area, provides virtual visits and phone calls for visitors to stay in contact with clients. Staff clean & disinfect throughout the day. Client's temperatures are taken once daily. LPA observed COVID-19 precaution postings and observed hand soap and paper towels available in the bathrooms. The facility has a supply of PPE including gloves, face shields, N-95 respirators, surgical masks and gowns. Facility staff have completed COVID-19 related training's such as donning/doffing PPE with RN/Instructor. LPA verified vaccination status for staff who were present during this visit, Administrator will submit copies of staff's vaccination status and/or surveillance testing.

LPA discussed the following requirements with Administrator:

· Facility to obtain N-95 mask fit testing for staff (Cal/OSHA requirement)

· Document all daily temperatures for clients & staff

LPA requested the following updated forms to be submitted to Community Care Licensing by 07/25/2022:

· 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 Administrator, whose signature on this document confirms receipt. **No deficiencies cited during this inspection