Routine inspection·May 16, 2025

At approximately 12:10PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1-Year Visit and met with Staff Members, Sheaena Hocog and Breana Chargualaf . Licensee/Administrator, Harry Van Meines, arrived during visit at approximately 1:00PM. Facility is a Residential Home for the Elderly and provides care and assistance for Older Adults. Facility has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 individuals. Upon arrival, LPA was informed that there were 6 residents in care, and 2 staff members on-site. At approximately 12:25PM, LPA reviewed the Facility's Staff Roster and all staff on-site were background cleared and associated to the facility per regulation. LPA conducted a walk-though of the facility. LPA observed the following: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story residence with 5 resident bedrooms, two and a half bathrooms, two staff rooms, and common areas. 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. 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. Hot water temperatures for all sinks in facility were out of compliance with Title 22 regulations measuring over 120F (deficiency cited, LIC809D, regulation 87303(e)(2)). Fire extinguisher was last inspected November 2024. Smoke detectors and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted April 2025. LPA reviewed staff files, 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. Continued on LIC809C Continued from LIC809 During medication review, LPA observed that 3 of 6 residents did not have their medication centrally stored and logged as required (deficiency cited, LIC809D, regulation 87465(h)). Administrator's Certificate for Henry (Harry) Van Meines (7020155740) was current with an expiration date of 08/18/2025. LPA requested the following documents to update facility file: Designation of Facility Responsibility (LIC308) Emergency Disaster Plan (LIC610E) Personnel Report (LIC500) Register of Clients/Residents (LIC9020) Updated Liability Insurance Active and Current Administrator Certificate Documents to be submitted to Community Care Licensing (CCL) by due date of 06/16/2025. 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 Administrator. Signature on form confirms receipt of documents.