Routine inspection·July 2, 2025

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit, and met with Staff Member, Edelyn Dacayanan . Designated Representative, Bella Nachor, arrived during visit at approximately 9:50AM. Facility has an approved fire clearance for five non-ambulatory residents and 1 bedridden resident for a total capacity of 6 residents and an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there are 5 residents in care and 3 staff members on site. At approximately 9:15AM, LPA reviewed the Facility's Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of facility with Staff Member and observed the following: Facility is a one story residence with 5 resident bedrooms, one staff room, three bathrooms, and common areas. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. 2 of 3 facility sinks were found to be within Title 22 Regulations of 105F to 120F. One facility sink located in a resident room was measured to be 125.2F (deficiency cited, LIC809D, regulation 87303(e)(2)). There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. All resident rooms were furnished per regulation with a bed, lamp, dresser, chair and bedside table. Facility has indoor/outdoor areas for visiting and activities. Facility's fire extinguishers were inspected December 2024. Facility's smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted June 2025. Continued on LIC809C Continued from LIC809 LPA observed that there is a small storage space between one resident room and the facility staff room. This space is not shown on facility's sketch. LPA was also informed that the current staff room may be converted into a private resident room. LPA requested that an updated facility sketch be submitted to Community Care Licensing (CCL) to reflect changes. A new fire clearance request will be submitted if it is determined that the staff room will be converted into a private resident room. LPA reviewed staff and resident files and resident medication. All files were all found to be well organized, thorough and contained the required documentation. Staff files had current First Aid and CPR certification. Medication was centrally stored and secure. Administrator Certificate for Stephanie Ellazar (6070922740) was current with an expiration date of 06/06/2026. Administrator Certificate for Bella Nachor (7008140740) was current with an expiration date of 05/27/2027. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC 308) Emergency Disaster Plan (LIC 610E) Updated Personnel Report (LIC 500) Updated Liability Insurance Active and Current Administrator Certificate Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 08/02/2025. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Designated Representative. Signature on form confirms receipt of documents.