Facility Evaluation Report

On 8/8/23 at 9:23 AM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by Client Care Coordinator (C3) Jessica Mata. Administrator (ADM) Tammy Isam arrived a short time later.

LPA toured the facility. No obstructions observed. Smoke and carbon monoxide detectors tested and operational. Facility set at comfortable temperature. All bedrooms observed with sufficient furniture and lighting. Fire extinguisher last serviced 12/27/22. Sufficient linen and toiletries observed. 2-day perishables and 7-day non-perishables supply of food observed sufficient. Sharps are kept locked in kitchen drawer. Chemicals observed locked in storage unit in garage and in the laundry room cabinet. Centrally stored medication observed locked in hall closet. Staff and resident files reviewed. Administrator certification pending completion of review.

1. Shared full bathroom observed with flooring lifted by shower, lining between shower and flooring observed cracked, door track for sliding door observed covered with dirt/debris, and the magnet locks for knife drawer and laundry detergent/cleaner cabinet observed non-operational.

A deficiency is being cited based on LPA observation in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted and a Plan of Correction was reviewed and developed with the Administrator. A copy of this report and appeal rights were discussed and left with Administrator, whose signature on this form confirms receipt of these documents.

The following updated forms are to be submitted to CCL within 2 weeks:

LIC308, LIC500, LIC9020, LIC400, LIC402, and LIC610D (new revision)