Post-licensing visit·July 2, 2025

On 07/02/2025 at 1:35PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced post licensing inspection. LPA met with Caregiver, Jacqueline Samayoa. Jacqueline contacted the Administrator, Henry Paul Salazar, via telephone and advised the purpose of the visit. The administrator arrived at 2:14PM, LPA explained the purpose of visit. LPA toured facility including but not limited to bedrooms, bathrooms, dining area, living room, kitchen, garage, and outdoor area. The fire extinguisher was observed to be full and last serviced on 04/15/2025. Medications were in a locked cabinet located in the kitchen. Comfortable room temperature is maintained at 76 degrees F. Hot water temperature in the shared residents’ bathroom was measured at 121.4 degrees Fahrenheit. Carbon monoxide and smoke detectors were observed in operating condition. The first-aid kit was complete, and hygiene items for resident general use are sufficient. Extra linens and towels were observed. Last fire drill was conducted on 2/26/2019. There are no accessible bodies of water observed. Continue on LIC809C Continued from LIC809 LPA reviewed all four (4) residents’ records, and two (2) staff records and they were complete. All staff are fingerprint clear, have FirstAid/CPR and are associated with the facility. The following forms are to be updated and submitted to CCL by 07/09/2025 : LIC 500- Personnel Report LIC 308- Designation of Facility Responsibility LIC 610E- Emergency/Disaster Plan (9 pages) Evidence of Liability Insurance LPA observed the following deficiencies: At 2:09PM, LPA observed during facility tour, facility does not have 7- days of nonperishables and 2- days of perishables At 3:22PM, LPA observed two (2) out four (4) personnel records were not at the facility during record review. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.