Routine inspection·July 8, 2025

*This is an amended report from visit on 07/08/2024-LPA issued correct deficiencies on LIC809 Annual Continuance Report dated 07/15/2025 On 07/08/2025 at 11:00AM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced 1-Year Required inspection. LPA met with Berthgeline Corpuz, caregiver and explained the purpose of the visit. Berthgeline contacted the administrator via phone. Administrator, Bharat Verma arrived at approximately 12:26PM. The Administrator currently holds a certificate #6072069740 that expires on 05/08/2026. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility has six (6) bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature is maintained at 78 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars. Hot water temperature in the shared clients’ bathroom was measured at 117.1 degrees Fahrenheit. 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 purchased on 06/12/2024. Emergency Disaster Plan was last posted on 07/08/2025. First aid kit was observed to be complete. Continue on LIC809C Continued from LIC809. LPA attempted to review three (3) staff records, one (1) out of three (3) were present at the facility and complete. LPA reviewed three (3) resident records which were complete. LPA observed the following deficiencies: At 11:18AM, LPA observed Medication (Terazosin and Daily Vite multivitamins) on table near computer in common area near the table residents were sitting eating breakfast At 11:27AM, LPA observed two (2) out of the three (3) individuals inside facility during visit, were not fingerprint cleared and associated with the facility per guardian At 11:53AM, LPA observed an unlocked kitchen cabinet with Simple Green all-purpose cleaner, Cascade platinum plus dishwasher pods, Fabuloso, Insect and Pest Control spray, Hydrogen Peroxide Topical Solution and Lysol Power Cleaner Concentrated multi-surface cleaner At 11:59AM, LPA observed unlocked prescribed medication Nystop POW 100,000mg on stand near residents’ bed At 12:00PM, LPA observed resident in bedroom with oxygen equipment near bed At 12:08PM, LPA observed alterations between the linen closet and the master bedroom closet (expansion). At 12:10PM, LPA observed unlocked laundry room with Tide Simply all in one laundry detergent Continue on LIC809C Continued from LIC809C At 12:12PM, LPA observed an unlocked cabinet in shared restroom with Seventh Generation toilet bowl cleaner, Lysol disinfecting wipes and Clorox multi-surface cleaner At 12:21PM, LPA observed a large black tent in garage with a complete bed with pillows, sheets and blankets, a foldaway bed, clothing hanging on a rack, bags and a Victoria super soft blanket in a clear carrying bag. At 3:48PM, LPA observed during file review one (1) out of three (3) staff records were present at the facility and complete LPA requested the following documents to be submitted to CCLD by 07/15/2025 . LIC9020 Resident Roster LIC 308 Designation of Administrative Responsibility Liability insurance. LIC 500 Personnel Report(updated) LIC 610E Emergency Disaster Plan. Deficiencies are 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. *An immediate civil penalty of $200.00 will be assessed on today's date* ($100.00 x 2 for each person’s presence in the facility and not fingerprint cleared) Exit interview conducted. A copy of the appeal rights, LIC421BG, and this report provided