Routine inspection·May 20, 2025

Licensing Program Analysts (LPAs) Blanca Gonzalez and Nune Margaryan conducted an unannounced annual visit using the Care Tool. LPAs met with Administrator Herminia Pegollo who assisted with visit. LPAs explained the reason for the visit. The facility is licensed for residents age range 60 and over. Approved for 6 non-ambulatory residents of which 1 may be bedridden. Facility approved Hospice waiver for 6, The facility is a single story structure located in a residential neighborhood. It consists of the following: (3) resident bedrooms, (1) staff bedroom, (1) resident bathroom, (1) staff bathroom, kitchen, dining room, living room, laundry room, detached garage. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. LPAs toured the facility. All indoor and outdoor passageways were free of obstruction. The kitchen was inspected. LPAs observed all kitchen equipment to be clean and in working condition. LPAs observed sufficient supply of perishable and non-perishable foods. Sharps, cleaning supplies are locked and inaccessible to residents. Smoke / Carbon monoxide detectors were in compliance and operational. There are (3) fire extinguisher located throughout the facility which are fully charged. The common areas (dining room, living room) are clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings. Medications are centrally stored in a locked cabinet in the kitchen. LPAs observed discrepancies in medication file documentation and administration for R1, R2 and R3. LPAs observed detached garage/ storage room. There is second refrigerator in the garage. Garage/Storage door is locked. Continued on 809C The resident bathroom is clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested and maintained within the required range of 105-120*F. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Last emergency/ fire drill was conducted on 05/16/25. LPAs reviewed 4 residents and 2 staff files. Residents’ files were found to be complete and current. LPA observed staff maintained a criminal record clearance and are associated to the facility. Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview conducted with administrator and a copy of this report and appeal right were provided.