Routine inspection·January 12, 2026

Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Vilma Bohanan, administrator for the facility, and explained the purpose of the visit. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: · Infection control plan is on file. Physical Plant/Environment Safety: · The facility is a two-story home located in a residential neighborhood. The facility consists of a kitchen, a dining room, a living room, a laundry room, a staff and caregiver bedroom, four (4) resident bedrooms, two bathrooms of which Restroom #1 had a hot water temperature reading of 109.2 Degrees Fahrenheit, and Restroom #2 which had a hot water temperature reading of 111.1 Degrees Fahrenheit., and a detached ADU. Administrator was advised to submit an updated facility sketch to LPA and also associate the family member living in the ADU. The facility was observed to be in good repair. · The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. The facility has a fully charged fire extinguisher kept in the facility. Operational Requirements: · The Program Design was reviewed. · Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, five (5) of whom may be non-ambulatory, one (1) of whom may be bedridden, and a hospice waiver approved for one (1) resident. · There are two (2) residents, Residents #1 and 2 (R1 and R2) who are listed as bedridden according to their physician’s reports, which exceeds the limit indicated on the license. · Care and supervision to meet the clients’ needs was observed. Staffing: · Five (5) full-time staff members provide care and supervision to the clients. Personnel Records/Staff Training: · Five (5) staff files were reviewed for criminal background clearance and training. · All Five (5) staff records reviewed have a health screening with a Tuberculosis clearance, and five (5) staff have First Aid/CPR trainings that are active. · One (1) new staff member Staff #3 (S3) still needs to have their initial 40-hour training conducted and documented by the administrator. · The administrator’s certificate expires on 11/24/2027. Resident Rights/Information: · Physician orders were reviewed for six (6) resident files. · Medications were also reviewed for six (6) residents. · Residents #3 and #4 (R3 and R4) had prescription medications that were not present in the facility. Resident Records/Incident Reports: · Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, and appraisals were reviewed. Food Service: · The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Incident Medical and Dental: · All residents have an Appraisal/Needs and Services Plan on file. Disaster Preparedness: · Emergency and Disaster Plan (LIC610E) was posted in the facility. · The last emergency and disaster drill was conducted on 12/30/2025. Planned Activities: · Sufficient Space is provided to accommodate both indoor and outdoor activities. · Sufficient equipment and supplies are provided to meet the requirements of the activity program. Residents with Special Health Care Needs · There is one (1) resident that has half-bed rails on their bed, however they do not have a physician’s order on file. · There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809D pages. Exit interview held and a copy of the report along with appeal rights were provided.