Facility Evaluation Report

On 11/22/22 at 9:05 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA explained reason for inspection and was granted entry by staff. Licensee/Administrator (LIC) Eesaeng Martinez arrived a short time later.

LPA toured inside and outside of the facility, and did not observe any obstructions. Social distancing is maintained in the common and dining areas. Hand washing posters were observed by the bathroom sink. Bedrooms were checked. LPA checked residents’ medications. Cleaning and PPE supplies were checked. Staff files checked for health assessments.

1. LPA observed fire extinguisher in kitchen area was last serviced 9/16/21.

2. Exterior fire exit gate observed sticking and not opening/closing with ease, and latch not reachable to exit gate; back patio observed covered with dried bird droppings, tile flooring throughout living area, kitchen, and dining area observed unswept; and numerous empty and full boxes observed stored in open front office area and in garage.

3. Box of knives observed stored in closet where cleaners/chemicals are kept.

4. Nonperishable food was not of minimum of one week supply.

Deficiencies are being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC809D.

The following updated forms to be sent to CCL within 2 weeks:

-LIC500, LIC400, LIC402, LIC610D (new revision)

Exit interview conducted and a Plan of Correction was reviewed and developed with Licensee. A copy of this report and appeal rights was given to Licensee Eesaeng Martinez, whose signature confirms receipt of this report.