Routine inspection·July 29, 2025

Licensing Program Analyst (LPA) Vaid conducted an unannounced required annual inspection. LPA met with Caregiver Luz Macalisang and explained the purpose of today’s visit. Administrator Yenny Indrawati was notified and arrived shortly after. This facility is licensed to serve three (3) non-ambulatory and three (3) ambulatory residents over the age of 60. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. Facility may retain no more than five (5) hospice residents. There are two (2) residents receiving assisted care. The facility is a single-story dwelling located in a residential neighborhood. LPA utilized the CARE tools for the visit today and observed the following: Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The facility has plan to accept or retain clients with dementia. The facility has proof of liability insurance, and will email copy to LPA. The 1-story facility consist of the following: 5 Resident Bedrooms and 3 Resident Bathrooms, dining room, living room, TV room, and backyard area. Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons were observed to be inaccessible to residents. Carbon monoxide detectors and smoke alarms in hallways operational. LPA inspected two (2) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in bathrooms were measured within 105 – 120 degrees F., observed grab bars near toilets. Nonskid mats and shower chair were observed. Sharps and knives are inaccessible to residents. Laundry machine working properly. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Fire extinguisher is fully charged. Continued on 809C.......... Staffing: Administrator Certificate for Yenny Indrawati and it expires 02/17/2027. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Staff is participating in continuous trainings. CPR and 1st aid. P ersonnel Records Training: Staff files are maintained at the facility. LPA observed required annual training, CPR and First Aid for two staff personnel records reviewed. Observed TB testing, Health screening, fingerprint clearance for two (2) out of the two (2) personnel records reviewed. Food Service: LPA Vaid observe sufficient supply of nonperishable for one week and perishables for 2 days. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Health Related Services/Incidental Medical Services: Medications are centrally stored in the kitchen cabinet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MARs) log to document medications given. The facility provides incidental medical services. Resident Records/Incident Reports: LPA reviewed two (2)resident files, files are maintained at the facility. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. LPA Vaid observed facility sketches with exits and emergency exits routes throughout various locations of the facility. Emergency drills(fire and earthquake) were last conducted 7/19/25. Residents Rights-Information : LPA observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA observed a facility land line. Residents with Special Needs: Staff does not use manual restrictive devices. No Deficiencies were observed on todays' visit. Copy of report given to Administrator Yenny Indrawati. Licensee will forward to case carry LPA Gonzalez pertinent documents regarding the ADU addition to the facility. Updated LIC 200, physical plant sketch. From city of Glendora: Occupancy class code, permits and pertinent documents received from city of Glendora planning department.