Community Care Licensing

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Licensing Program Analyst Ryker Heberle (LPA) conducted an unannounced annual inspection on 08/04/2022 at 10:53am. LPA met with facility Administrator Vicky Ablao (Admin). At 10:56am, LPA began touring the facility inside and out including living room, kitchen, dining room, garage, family room/activity room, 3 bathrooms, 6 bedrooms including staff bedrooms, storage room, back yard, and side walkways. All staff members observed to be wearing masks. Admin confirmed that all staff and residents have been vaccinated. Facility infectious control plan has already been submitted. No prohibited items noted in resident rooms. All emergency exits noted to be clear of obstruction. All rooms in facility noted to be clean and well maintained. Hand sanitizers, soap, and paper supplies were observed to be available. All restrooms stocked with paper towels. Facility water temperature measured to be 110.1*F. Hand washing signs observed in all bathrooms. Social distancing signs observed to be posted in all public areas. Facility observed to have designated entry point. Staff took LPA's temperature, screened for symptoms, and recorded information in visitor log. At least 2 days' supply of perishable food and at least 1 week's supply of non-perishable food was observed on the premises. 30 day supply of PPE observed. Fire extinguisher tags indicate it was last inspected in May of 2022. 8 Carbon monoxide/smoke were observed throughout the facility. No deficiencies cited during today's visit. This report was reviewed with Administrator Vicky Ablao and a copy of the signed report was provided.

SUPERVISOR'S NAME: Sarah Yip TELEPHONE: (408) 324-2131 LICENSING EVALUATOR NAME: Ryker Heberle TELEPHONE: 714-328-5152 LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022