Facility Evaluation Report

At approximately 8:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Mariana Sanchez. Designated Representative, Guadalupe Rivera, arrived during visit at approximately 9:00AM. Licensee, Christine Woltering, arrived during visit at approximately 1:40PM. Facility serves older adults and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 6 non-ambulatory residents of which 1 resident can be bedridden. Facility has an approved hospice waiver for 1 individual. Upon arrival, LPA was informed that there were 5 Residents in care and 2 staff members on-site.

At approximately 8:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. LPA also observed that the significant other of a staff member lived on-site. Review of Facility's Staff Roster indicated that this individual was not on the Facility's Staff Roster. Per conversation with facility staff, this individual does not provide direct care to the residents. LPA confirmed on the Guardian website that this individual was background cleared but not associated to the facility as required. LPA observed individual be associated during visit.

** Administrator understands that a civil penalty is not being issued today for individual because they were associated to the facility during visit.**

At approximately 9:35AM, LPA conducted a walk-though of the facility with Designated Representative. Per Facility sketch, facility is a one story building with 6 bedrooms, 3 bathrooms, and common spaces. During visit, LPA observed a granny unit on-site that was not indicated on the facility sketch. LPA and Designated Representative discussed submitting an updated facility sketch (see Technical Violation, LIC9102, Regulation 87208(a)(7)(A) ) . Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file.