Routine inspection·September 11, 2025

Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced annual required visit and inspection of the facility. Upon arrival LPA met with John Lingad and explained the reason for the visit. LPA spoke with Administrator - Josefina Lacsamana over the telephone. At approximately 12:10pm Administrator came to the facility and met LPA. The facility is licensed to serve six (6) non-ambulatory residents with an approved waiver for three (3) hospice residents and one (1) bedridden resident. At 10:45am, with the assistance of Staff, LPA took a tour of the physical plant. The facility is a one story structure with six (6) bedrooms, three (3) bathrooms, kitchen, dining area, living room and office area. Required postings were observed in the entry area. The smoke alarms/carbon monoxide detectors are battery operated. At 11:15 am smoke/carbon monoxide detectors were tested and observed to be functional. There are four fire extinguishers, located in the kitchen, dining room, living room and in the hallway next to bedroom #5. All fire extinguishers were observed to be full and serviced together on 1/23/2025. The auditory alarms on all exit doors were functional at the time of the visit. Facility conducts quarterly fire and earthquake drills. The last fire drill was conducted on 06/15/2025 and earthquake drill was conduced on 08/15/2025. Common Areas: These included the living room and dining room. The common areas were properly furnished with tables and chairs for the number of residents. A piano and keyboard were seen in the dining room and a television and cabinets with games, karaoke machine in the living room. There is a linen closet in the hallway, near the bedrooms. Laundry Room: The laundry room is accessed through a locked door from the living room. LPA observed chemicals and detergents stored in cabinets, in the locked laundry room. Continued on 809-C 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 a kitchen cabinet. Kitchen chemicals and detergents are stored in the locked laundry room. The kitchen has a eating area with table and office area, on one side and has 2 exit doors. Bedrooms: There are total of six (6) bedrooms. Bedrooms #1-5 are designated for residents' use and bedroom #6 is used for staff use/live-in staff room. All bedrooms are properly furnished with appropriate beddings, chairs, cabinets, linens and have sufficient lighting. Bathrooms: There are three (3) bathrooms, two (2) of which are designated for residents' use and one (1) for staff. LPA observed functional fixtures, grab bars and non-skid mats in each bathroom. Hot water temperature at resident bathrooms was measured at 115.6 and 120.5 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. Facility does not use the front entry door, the entrance is from the front, side gate, leading to the living room. There are two exits doors in the kitchen, there are exits in the living room, dining room and in all the bedrooms. Facility uses the front side gate as the main emergency exit door. There is a detached garage, currently used as storage. LPA observed two refrigerators and cabinets for emergency food in the garage. LPA observed a milk carton with expiration date of 09/01/2025 and several expired cans in the cabinets. Administrator immediately destroyed and trashed the expired items; a citation will be provided. Resident Files/Medications : Files for all six residents were reviewed for completion of required documents. Medications for three out of six residents were counted for accuracy of administration based on physician orders. LPA observed a complete first aid kit and the manual in the locked medication cabinet. Staff Files : LPA also conducted a file review of 5 staff records to insure forms and training are up to date and in compliance with licensing requirements and staff have been cleared and associated with the facility. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was observed during the visit and citation and appeal rights provided. Exit Interview conducted / A Copy of the Report Issu ed to the Administrator.