Ajaviniar Home Care Services Llc

LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 3 client bedrooms, staff room, two bathrooms, kitchen and living/dining room. There are 2 detached storage units in fenced backyard beyond covered patio. Washer and dryer are located outside on side of building, in covered walkway. There is one car garage. No accessible bodies of water or fire safety hazards observed. PPE supply is inspected. Food supplies are maintained. A comfortable temperature is maintained, lighting is sufficient for comfort and safety and hot water temperature tested at 107 degrees. Toilet and bathing facility is equipped with grab bars and nonskid flooring material. Liquid soap is available at bathroom sink. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 2 residents present and 1 staff. No one is currently receiving hospice services. Three client records are reviewed. One resident's file is not on site, as it is with administrator and client for annual review meeting. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including current first aid training and health screenings. Rowena Cruz Diaz has an expired RCFE administrator certificate (x 2018). The following information/forms are provided: - Proof of current liability insurance - Designation of Administrative REsponsibility (LIC308) - Personnel REport (LIC500) - Emergency Disaster Plan (LIC610D) - Infection Control Plan - Proof of current surety bonding Licensee is requested to submit the following information/forms to CCLD BY 2/10/25: - Administrative Organization (LIC309) - Bedridden plan of operation Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Technical Advisory Note is also issued--1 page.

On 01/17/2023, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with caregiver Leo Sison and explained the purpose of today's visit. LPA was informed upon entry that there is one COVID positive resident in care at this time. The resident is quarantined in their room. Infection control protocols are discussed and testing of residents and staff are conducted weekly. LPA was allowed entry into the facility. This is a one level facility. Annual Fees are not current per review made on 01/09/2023 of facility file. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is organized and observed appliances are in good repair. Knives are stored under the kitchen sink locked and not accessible to residents. Spray bottle type cleaning supplies are also locked below the kitchen sing. Cleaning solutions are also locked in a cabinet outside of the facility adjacent to the washer and dryer. Perishable and non-perishable food items are observed as in place. LPA observed the medications as in place and locked in a closet. The first aid kit observed as complete with required items. LPA observed that the facility is equipped with, fire extinguisher located the back door adjacent to the kitchen, smoke detector/carbon monoxide detectors are observed in place in resident rooms and central hallway connecting resident rooms, and central heating system is operating. PPE and additional food supplies are observed as in place in the exterior shed of the facility. Laundry area is also observed as fully operational located outside of the facility under sheltered roofing. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 112F in common resident bathroom. Continued on next page. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LIC809C - Annual LPA observed several resident rooms at random and all rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. COVID PPE and resident incontinence supplies are observed in place inside the facility as well as in storage areas outside of the facility. Disaster drill is conducted quarterly, last conducted on 06/06/2023. Facility does not handle resident monies. Administrator certificate is observed as expired on 10/05/2018. The following updated forms are being requested to be received by 01/24/24 : • LIC610D Emergency Disaster Plan • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report • Updated administrator certificate • LIC9020 Client Roster • Certificate of Liability Insurance Citation issued on the following LIC809D. Report is reviewed with Leo Sison.