Routine inspection·March 2, 2026

Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conducted an Annual Required Inspection visit. When LPA arrived she was greeted by the house manager, Dulce Villeros. Staff contacted the Administrator, Jojo Cajayon and informed him LPA was at the facility. LPA explained the purpose of the visit. Administrator was not able to meet LPA at the facility but would be available by telephone for questions. At 9:23 AM LPA requested a copy of the facility's Emergency Disaster Plan (LIC610E), Personnel Report (LIC500), Register of Facility Residents (LIC9020) and a copy of the facility's Liability Insurance. LPA obtained copies for review and to update the Regional Office file. At approximately 9:33 AM, LPA initiated the physical plant tour of the facility inside and out. At the entrance, LPA observed required postings on the wall by the front door and a small table with a visitor sign-in along with hand sanitizer. The facility has an open concept layout that includes the kitchen, living area, and dining area. In the kitchen LPA observed appliances and fixtures were functional. LPA observed two refrigerators stocked with a sufficient supply of two day perishables, and the pantry and kitchen cabinets contained an adequate amount of seven day non perishable food. LPA also observed fresh fruit available in the refrigerator and on the kitchen counter. LPA observed knives and sharps were stored in a locked drawer. LPA observed the cabinet under the kitchen sink was locked and it is used to store cleaning supplies. In the living area and dining area LPA observed the furniture to be in good repair and sit the capacity of the facility. LPA observed the fire extinguisher on a wall by the dining area. LPA observed one (1) resident in the living room watching television. The fire extinguisher was fully charged and has a last serviced date of 05/16/2025. LPA did not observe tripping hazards. (Continue to LIC809-C) (Continued from LIC809) The backyard has a table with chairs for residents' use. LPA observed the passageway to the exit was clear of obstruction. The backyard has sufficient space for residents. There is no swimming pool or bodies of water. On the side of the house not leading to an exit LPA observed a mattress and other furniture piled on top of each other. According to the administrator they will schedule a bulk pick up to clear the space. LPA observed a locked shed used for storage. The facility has two (2) bathrooms . The bathrooms are next to each other by bedroom #6. LPA observed that the bathrooms were equipped with functioning plumbing fixtures, required grab bars, non-skid mats and supplied with toilet paper, hand soap and paper towels. LPA measured the hot water temperature in both bathrooms between 9:50 AM and 9:55 AM with readings of 117.2°F and 114.1°F, within regulation. LPA observed a locked cabinet where centrally stored medication and medication records are stored. leading to the bedrooms. The facility has a fully stocked first aid kit an first aid manual. There are six (6) bedrooms designated for residents. Bedrooms are private. The facility has a fire clearance (STD850) dated 09/10/2019, indicating approval for five (5) non ambulatory residents and one (1) bedridden resident for a total capacity of six (6) residents. Bedrooms designated for residents were furnished with a bed, night stand, chair, dresser, bedding, sufficient lighting and closet space. Doors leading to the outside have auditory alarms there were on and functioning properly during the visit. In bedroom #1 and bedroom #2 LPA observed open windows without a screen. The facility is equipped with dual carbon monoxide and smoke detectors that are interconnected through out the facility. LPA observed the house manager test a detector at 11:13 AM and it was working properly. The facility has no garage. The laundry room is maintained locked. In the laundry room LPA observed a washer and dryer. Detergents and cleaning supplies are kept in the laundry room. There is an office space by the laundry room that has facility, staff, and residents records and is also used for storage of emergency water. (Con. to LIC809-C) Page 2 of 3 (Continued from LIC809-C) From 11:22 AM to 1:00 PM, LPA conducted a file review of five (5) resident files to ensure licensing forms were complete and in compliance. LPA's review of resident records revealed three (3) out of five (5) residents, Resident #2 (R2), Resident #4 (R4) and Resident #5 (R5) did not have a signed and dated Resident Appraisal and had blank Appraisal/Needs and Services (LIC625) forms. Appraisals on file were completed as pre admission appraisals. Residents have been in the facility for more than 12 months. LPA's review Physician's bed rail orders do not indicate whether it is for half bed rail or full bed rail for those residents with bed rails on their bed. Administrator will obtain orders that indicate the length of the bed rials. Centrally stored medication and medication records were reviewed for proper storage and documentation. In addition, LPA also conducted a file review of two (2) staff records to insure training documents are in compliance and complete. LPA did not observed the annual training record for the house manager. According to the house manager and the administrator training had been conducted but training documentation had not been filled out. LPA’s review of the facility’s quarterly emergency drill records, along with an interview with the house manager, revealed that they had not participated in an emergency disaster drill at the facility within the past year. LPA reviewed the Pending Administrator Certification List and observed Administrator's name on the list. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were deficiencies observed during this visit. Refer to LIC809-D. LPA also provided LIC9102TV and LIC9102TA to house manager. Exit Interview was conducted with the Administrator by telephone. Copy of Appeal Rights and a copy of the report provided to the house manger. Page of 3 of 3