Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Joanne Samson, back-up administrator . The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. LPA toured the facility, all exits were unobstructed, and the facility was found to be clean & at a comfortable temperature. Facility has a COVID-19 screening station. Designated staff have current CPR/first aid certifications in file. Fire extinguisher was charged and serviced 07/25/2022. The facility has an ample supply of PPE. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms. The facility has submitted their Infection Control Plan to the California Department of Social Services, Community Care Licensing. During this visit, LPA verified staff COVID-19 vaccination records. All staff wore face masks during this visit.

LPA requested the following updated forms to be submitted to Community Care Licensing by 02/28/2023:

· 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.

LPA requested forms needed to update the facility Administrator to Joanne Samson:

· LIC215, LIC500, LIC308, LIC501, copy of Administrator certificate

Exit interview conducted with Back-up Administrator, whose signature on this document confirms receipt. ***No deficiencies cited during this inspection