Routine inspection·April 2, 2025

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced annual required visit and inspection of the facility. LPA met with Jorge Adle Mendoza - Administrator and explained the reason for the visit. The facility is licensed to serve six (6) residents ages 60 and above, of whom (6) may be non-ambulatory. Bedroom #3 has an approved waiver for two (2) hospice residents. Currently the facility has no clients in care. At 10:45am, with the assistance of Administrator, LPA took a tour of the physical plant. The facility is a one story structure with four (4) bedrooms, two (2) bathrooms, kitchen, dining area, family room, and living room/office area. Required postings were observed in the entry area. The smoke alarms/carbon monoxide detectors are hardwired and interconnected. At 11:05 am smoke alarms/carbon monoxide detectors were tested and observed to be functional. The fire extinguisher is located in the kitchen and was purchased on 7/1/2024. The auditory alarms on all exit doors were functional at the time of the visit. Common Areas : These included the living room, family room and dining area. LPA observed a double sided fireplace in the family and living rooms; both fireplaces were properly covered by a glass cover. The common areas were properly furnished with tables and chairs for the number of residents. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient supply of perishable (2 days) and non-perishable (7 days) foods at the facility. Knives were stored in a locked drawer in the kitchen. Chemicals and detergents were stored in a locked cabinet underneath the sink. Continued on LIC 809-C Bedrooms: There were four (4) bedrooms, three (3) of which are designated for residents' use. Bedroom # 3 is designated for hospice residents and bedroom #4 is designated as staff room. All bedrooms are were properly furnished with appropriate beddings, chairs, cabinets, linens and have sufficient lighting. Bathrooms: There are two (2) bathrooms, one near bedroom# 4 and one between bedrooms #2 and #3. LPA observed functional fixtures, grab bars and non-skid mats in each bathroom. Hot water temperature was measured at 120.2 degrees Fahrenheit. Surrounding Grounds : There were no bodies of water or obstructions on the premises. There is a covered patio with furniture appropriate for outdoor use. There is a locked shed in the backyard. The laundry machines and detergents are located in the garage, which is currently used for storage. There is a ramp leading from the living room to the backyard; there is also a side door in the kitchen and a door in bedroom# 4 leading to the backyard. Facility uses the main entry door as the emergency exit door. Resident Files/Medications : Since there have been no residents for over two years, LPA did not review resident records. LPA observed a complete first aid kit and the manual in a locked cabinet, which is designated for medication storage. Staff Files : LPA also conducted a file review of staff records to insure forms and training are up to date and in compliance with licensing requirements. Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies were observed during the visit. Exit Interview Conducted / A Copy of the Report Issued to the Administrator.