Medications: The facility has a locked medication cabinet in the kitchen for resident medications.

Physical Plant: Facility is clean, sanitary, and in good repair with a couple of exceptions listed below. There is a main family room, kitchen, laundry room, four bedrooms, and two bathrooms. Bedrooms #3 and #4 have furniture to occupy two residents in each room. Bedroom #4 is missing a second chair. Administrator will place a second chair in the room, take a photo, and send it to LPA. Kitchen cleaning supplies are kept in a locked cabinet under the kitchen sink. Bathroom cleaning supplies are in locked cabinets under sinks. Laundry cleaning supplies are in a locked cabinet above washing machine and dryer. Walls, ceilings, floors, and areas inside the facility are clean, painted and/or in good repair.

A fire extinguisher is located in the dining room with the dial in the green zone, however, the tag does not show it was inspected. Administrator will take the extinguisher to the fire department and have it inspected and compliance recorded. Administrator will take a photo of the fire extinguisher in the facility after the compliance has been recorded on the extinguisher tag, and send to LPA. Smoke detectors (5) and carbon monoxide detector (1) are in the hallway and bedrooms and were tested and working properly. Doors and passageways are unobstructed. The facility does not keep firearms or ammunition on the premises. Bathrooms are kept clean and in good repair. Water temperature in the hallway bathroom registered at 100 F degrees and the bathroom in Bedroom #3 registered at 101 F degrees. The facility maintains a comfortable temperature of 72 F degrees.

Continued on 809-C.

A first-aid kit, kit manual and supplies are maintained. Refrigerator is maintained at 40 F degrees and the freezer was recorded at 0 F degrees. Food storage and preparation areas are clean and appropriate for food preparation. All appliances are clean and operating properly. Food utensils, dishes, and glasses are clean and in good repair. All rooms are appropriately furnished for their intended use. The facility has a minimum seven days of non-perishable foods and three days of perishable items. There are no knives accessible to residents. Knives are kept in a locked drawer in the kitchen. Kitchen water temperature was tested at 111 F degrees.

Resident and staff records are maintained at the facility in the hallway/laundry room in a locked cabinet. Hallway cabinets have a good supply of linens.

The exterior gate securing the backyard has a working self-latching lock. The facility has a two-car garage with a delayed egress alarm going into to the garage from the house and also on the small door exiting the garage to the backyard. The sliding glass doors in the dining room and Bedroom #3 do not have screen doors. Administrator will install screen doors, take a photo, and send to LPA. The mirrored closet door in Bedroom # 1 is off-track. Administrator will repair, send a video of the door sliding properly, and send to LPA.

The facility has a 2004 Chevy EconoLine Van to transport residents. The van is currently located at Villa Care Home II, 946 W. Bunny Avenue, Santa Maria, and available for residents to use at Villa Care Home IV.

COVID screening was conducted on LPA upon entry to the facility. The facility has a table at entry with a thermometer, hand sanitizer, and visitor sign-in sheet with screening questions. The facility has a bottle of hand santizer in each room and plenty of hand soap and paper towels.

Items in underlined text are to be completed by 12/21/2021.

At 1:15 pm, exit interview was conducted with Jennifer Villaros and Jessica Rust and a copy of the report emailed.