Routine inspection·October 6, 2025

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Pandapotan Pardosi and oJcelyn Habaradas, Care Staff and explained the purpose of the visit. At 10:30am, Administrator Jennifer Manabat Leon arrived and assisted LPA with the inspection. The facility is approved to serve elderly residents age range 60 and over, (6) non ambulatory of which (3) may be bedridden. Facility is approved for (6) hospice waiver. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has Infection prevention and control plan, process, procedures and training plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date. Operational Requirements: Fire Drill is conducted quarterly and the last drill was conducted on 07/09/2025. Facility has working signal systems in exit points. Liability insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires on 06/01/2026. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the residents with special needs were observed. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood which consists of (4) resident bedrooms, (1) staff bedroom, (2) bathrooms, living room with covered fireplace, kitchen, dining area, laundry area in the attached garage and front yard with shaded patio area. There are currently (6) residents, of which (2) are under hospice care. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. LPA observed cameras outside the property. Front yard was inspected and has a shaded area and sitting area. There is (1) fire extinguisher in the facility which was serviced on 02/25/2025. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature reading measured within the required 105 - 120 degrees Fahrenheit. @ 10:35am, readings were 110.4 deg. F in bathroom #1 and 111.9 deg F in bathroom #2. *****REPORT CONTINUED ON LIC809-C***** Staffing: A total of (11) regular and on-call caregivers including the (2) Administrators provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Five (5) staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings. Administrator's certificate is valid through 08/08/2026. Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Information regarding Dementia is part of training for direct care staff. The facility provides sufficient space to accommodate both indoor and outdoor activities. Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. Facility has (2) extra refrigerators/freezers with food supplies in the garage. Pesticides and cleaning supplies are kept away from the food preparation areas. Incidental Medical Services: Residents' medications were reviewed during the visit. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications were stored in a locked cabinet in the hallway and inaccessible to residents. First-aid supplies along with a manual are maintained in the facility. Resident Records-Incident Reports: Resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, TB clearance, Personal rights, Medical Consent, Medication Records. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. The facility conducts emergency drill on a monthly basis. Last fire and earthquake drills were conducted on 07/09/2025. Residents with SHN: Two (2) residents are under hospice care. Physician orders for use of bed rails were reviewed in (6) resident files. No deficiencies cited, Technical Assistance issued. Exit interview and a copy of this report was provided to the Administrator, Jennifer Manabat Leon.