Routine inspection·September 5, 2025

On 9/5/2025 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Isigani Silvestre and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory of which 1 may be bedridden in room 2 only. LPA toured facility with Isigani Silvestre including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 total bedrooms which 5 bedrooms are occupied by the residents and 0 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 70 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 108.4 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. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last purchased on 3/28/2025. Emergency Disaster Plan was last posted on 3/1/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 6/15/2025. At 8:50 am, LPA reviewed 4 residents records. At 9:40 am/pm, LPA reviewed 2 staff records and 2 of 2 have current first aid training and 1 of 2 are associated to the facility. THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: Resident records were incomplete S2 not trained and was observed providing care unsupervised Garage was converted to staff living quarters and it was not been approved/cleared LPA observed that S2 is was not associated to the facility Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 10/01/2025: LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Current Administrator’s Certificate All forms to update Administrator 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.