Routine inspection·July 29, 2025

Licensing Program Analysts (LPA), Nadia Shabazian, conducted an unannounced annual inspection at the facility mentioned above. LPA met with Dominor Viernes-Caregiver and explained the reason for the visit. LPA spoke with Dina Alger - Administrator, over the telephone, who stated that she has a scheduled medical procedure and is unable to come. Administrator designated Dominor Viernes to sign the report. At approximately 1:20 pm, Administrator-Dina Alger entered the facility and met with LPA. The facility is approved for six (6) non-ambulatory residents, all of whom may be bedridden. Facility's hospice approval was increased to total of six (6) residents. Current census is four (4). At 9:40 am, LPA conducted a physical tour, with the assistance of staff and observed the following: Required postings were observed in the living room and dining room walls. The smoke/carbon monoxide detectors are hardwired and interconnected. At 10:20 am, the smoke/carbon monoxide detectors were tested and functioned properly. There are five (5) fire extinguishers located in the kitchen, front entry, hallway, patio and in the converted garage. All the fire extinguishers were fully charged on 08/01/2024. Kitchen: Appliances consisted of stove, dishwasher, microwave and refrigerator. LPA checks all the appliances for cleanliness and observed them to be clean and operational. All knives and sharps observed to be locked in a kitchen drawer and chemicals were locked underneath the sink, inaccessible to residents. The cabinets were supplied with plenty of non-perishable foods, for minimum of 1 week; and refrigerator was supplied with perishable foods for 2 days. There were plenty of dishes maintained in the kitchen cabinets. Thee kitchen has a door, leading to the laundry room. LPA observed laundry detergents and chemicals in locked cabinets. The laundry machines included one washer and one dryer, which were in functional mode. There is an exit door in the laundry room, which leads to the backyard. Continued on 809-C Common Areas : According to the facility sketch, the common areas included a family room, the living room and dining room. Based on the sketch, the living room is located by the entry door; the dining room is near the kitchen and the family room is a large space, also next to the kitchen. LPA observed that the licensee has repurposed the facility living room as living quarters for the licensee and family. The dining room is currently being used as the office/music room. The large family room is being used currently as a dining room and living room. The common areas were properly furnished with sofas and dining room chairs and table, appropriate for number of residents. In addition, living room was furnished with book cases and cabinets for gaming/entertainment. There are three storage cabinets for linens and supplies, one in the living room and two in the hallway. Facility is equipped with cable, internet and land line and cameras in front and back/side yard areas. Bedrooms: There are three (3) bedrooms for resident use. All bedrooms are shared but currently bedroom #2 is used as a private bedroom. Bedroom #3 has an exit door, leading to the backyard. All bedrooms were clean, properly furnished with dresser drawers, closets, chairs with ample lighting and bedding for the residents. Bathrooms: There are three (3) bathrooms, one (1) designated for residents' use, one (1) for the staff and one half (1/2) bathroom in the backyard patio/garage area. Both bathrooms in the house were properly supplied with paper towels, tissues and hand soap, and had functional fixtures (grab bars and non-skit mats). Hot water temperature was measured at 112.4 degrees Fahrenheit. Surrounding Grounds : There is a covered patio with furniture appropriate for outdoor use, for the number of residents. The outdoor area was free of hazards. There are two side exits in the backyard, but facility uses the entry door as the main exit. There is no body of water present. The garage is currently being used as storage/sleeping quarter for staff. There is also a half (1/2) bathroom outside of the garage/staff room. (Continued on 809-C) Medications: LPA observed all medications and Medication Administration Records (MARs) in a locked kitchen cabinet. A complete First Aid kit and the First Aid Manual was also observed. Resident records: All records were observed as locked and inaccessible to residents . Records for four (4) out of four (4) residents were reviewed for resident rights, physician reports, admission agreements and additional documents. Resident records appeared to be complete and current. Staff records: All records were observed as locked in the office area . A total of three (3) staff files were reviewed. Criminal record clearances were present, and staff are associated to this facility. Staff records appear to be complete and current. The Administrator admitted that ever since the Covid-19 Pandemic, licensee has been using the living room as living quarters for the family, without submitting any plan of approval from CCLD or submitting updated sketches. In addition the garage is also being used as temporary staff room, without prior approval from CCLD. Licensee will obtain permits, current sketch and fire inspection report for the garage and converted living/diring rooms and will submit them to CCLD within 30 days. Based on initial Plan of Operations submitted, the licensee will ensure that there are sufficient number of staff scheduled to work all shifts. Based on Title 22 Regulation: A new Plan of Operations and LIC 500 (Personnel Report) shall be submitted to CCLD within thirty (30) days, to ensure sufficient staff coverage during a 24 hour shift. Deficiencies cited during today’s visit. Appeal rights issued and given. Exit interview conducted and a copy of this report was given to facility Administrator.