Routine inspection·April 9, 2025

On 04/09/2025 at 9:45AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Thelma Hababag, Direct Care Staff and explained the purpose of the visit. Thelma called the Administrator who arrived to the facility at 10:33AM. Administrator currently holds a certificate (#7035384740) that expires on 10/04/2025. Facility has census of 5. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and three (3) bathrooms. LPA did not observe any bodies of water. A comfortable temperature is maintained at 69 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 111.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 12/17/2024. Emergency Disaster Plan was last posted on 01/17/2025. First aid kit was observed to be complete. Fire drill was last conducted on 01/30/2025. Continued on LIC809C. Continued from LIC809. LPA reviewed five (5) resident records, and five (5) staff records, and they were current and complete. LPA also reviewed a sample of medication during visit. LPA requested the following documents to be submitted to CCLD by 04/16/2025. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance LPA observed the following deficiency: At 11:35AM LPA observed during file review, facility did not have a dementia care plan as part of the facility's plan of operations. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided .