Routine inspection·January 3, 2025

On 01/03/2025 at 3:05 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Leonardo Alcantara, Jr. and explained the purpose of the visit. The facility’s fire clearance was approved for capacity of six (6) residents and non-ambulatory. Hospice waiver approved for one (1). Administrator certificate #7010842740 expires 10/04/2025. LPA toured facility with Leonardo including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of six (6) total bedrooms which five (5) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 78 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. LIC809-C Continued... LIC809-C (Page 2) Smoke and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/05/2023. Emergency Disaster Plan was not available. First aid kit was observed to be complete. Emergency disaster drill was not available. LPA reviewed one (1) resident's records. LPA reviewed two (2) staff records and 1 of 2 have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/10/2025: LIC 308 Designation of Administrative Responsibility - Reviewed LIC 309 Administrative Organization - Reviewed LIC 500 Personnel Report - Reviewed Updated LIC 610E Emergency Disaster Plan Liability Insurance - Reviewed Current Administrator’s Certificate - Reviewed The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.