Facility Evaluation Report

Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year inspection and met with Patricia Kurpieski, caregiver. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. LPA conducted a tour of the facility with Patricia, all exits were observed unobstructed. The facility has a screening station, LPA was screened upon arrival. LPA observed COVID-19 precaution postings. The facility has submitted their Infection Control Plan to be reviewed by the California Department of Social Services, Community Care Licensing. LPA verified staff's vaccination status for COVID-19 during this visit.

LPA discussed the following with Caregiver:

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

· Maintain a 30 day supply of Personal Protective Equipment (PPE) in the facility

· Document resident's temperatures on a daily basis.

LPA requested the following updated forms to be submitted to Community Care Licensing by 10/24/2022:

· 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.

· LPA requested documentation of physician's orders and exception request for bedrails to be submitted to CCL immediately

Exit interview conducted with Caregiver, whose signature on this document confirms receipt.

*No deficiencies cited at this time during inspection