Routine inspection·February 25, 2025

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Sayda Naz Hai. The following 12 (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was observed Physical Plant/Environment Safety: Facility is in a residential neighborhood and is two stories home, first floor consist of a kitchen, living room, family room, 3 resident rooms, 2 bathrooms, 1 staff room, an attached garage. The Basement is the administrator's residential area and inaccessible to the residents. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard. Cleaning supplies and toxic substances are inaccessible. Water temperature readings measured within title 22 regulations. Operational Requirements: A current Plan of Operation observed. Dementia Care Plan on file A fire clearance for total 6 residents of which (5) may be Non ambulatory and (1) bedridden Hospice care waiver approved for up to three (3) residents. Personnel Records - Staff Training: Administrator on file is current Staff have criminal background clearances. Three (3) staff files were reviewed. Continued on LIC 809-C Staffing: Sufficient staff observed during visit Resident Records - Incident Reports: A total of five (5) resident files were reviewed. Resident Rights - Information Required postings observed Food Service: Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for clients to use and to store their meals Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Incident Medical and Dental: First Aid Kid observed (5) of (5) Resident medications reviewed Disaster Preparedness: Emergency and Disaster Plan observed Last Emergency Drill conducted 12/1/24. Residents with Special Health Needs: Currently (2) residents receiving hospice services. Hospice care plans observed Inspection Tool was completed and per Title 22 deficiencies are being cited on todays visit. See 809-D pages attached Exit interview conducted. Copy of this report and appeal rights were discussed and provided.