Facility Evaluation Report

Licensing Program Analyst (LPA) Alviso conducted a case management to continue the Required- 1 Year visit, of 4/18/23; LPA conducted the continuation visit on 6/1/23 at approximately 9:15am, and met with caregiver Pam Watkins. There are five(5) residents in care. Caregiver Raffia arrived to the facility to help provide, to the LPA, facility records, including resident and staff records.

LPA received an updated LIC200 application form, and an updated facility sketch, for the change of capacity from six to five, as only one resident room will remain as a shared room, all others will be private. LPA will request a fire clearance inspection, and notify the licensee when the request is sent out.

Per review of the Fire/Disaster records, the last two evacuation fire drills were completed on 2/13/23 and 5/18/23.

The LPA is reviewing five(5) of five(5) resident files. The LPA is reviewing six(6) of six(6) staff files. All staff have required criminal record clearance

LPA observed that one(1) out of five(5) resident files was not on-site or available for review. Staff could not provide residents file to the LPA. This deficiency will be cited, 87506(b) (b) Each resident's record shall contain at least, all documents required by regulation , see LIC809D

Per LPA record reviews, staff had no training and/or had incomplete training. Staff #1, staff #2, staff #4, and staff #5, lack 20 hours of required completed training. Four(4) out of six(6) staff lack required training hours. This will be cited, H&S Code 1569.625(b)(2), see LIC809D.