Routine inspection·June 25, 2025

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 4 residents and the home currently has 2 residents, with 1 resident on hospice. Administrator (AD) Joselito Rivera arrived shortly to conduct facility tour. AD provided updated liability insurance that expires on 2/16/2026. AD certificate expires on 10/3/2026. LPA along with AD toured the facility at 9:05 AM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of 4 resident bedrooms, living room, dining room, staff room and kitchen as well as 2 bathrooms on the first floor. The second floor consists of 3 bedrooms and living room used by the AD. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure. At 9:30 AM, LPA observed shower floor dirty with stains, transfer chair with rusted wheel brackets, and cleaning power in unlocked cabinet in resident bathroom. Water temperature measured 115.7 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. At 9:45 AM, LPA observed furniture blocking sliding door exit access in rooms 3 and 4. Three auditory exit alarms were non-operational. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. Outside grounds were toured. At 10:00 AM, LPA observed clutter in the backyard including an old mattress, other large items designated for removal as stated by AD, and various small items stacked around the house which can be difficult to navigate through. There is plant overgrowth along one of the exit paths covering a large portion of concrete. Continued on LIC809-C Exit gates are unlocked and operational. First aid kit contained all required items including tweezers, scissors and thermometer. LPA observed the emergency food supply. LPA reviewed emergency disaster plan. There was no infection control plan to review. There is no evidence of disaster drills being completed this year. LPA reviewed two resident files and two staff files. All resident files contained required documentation including admission agreements, physician reports, and resident appraisals. Staff files reviewed contained required documentation including medical assessment/ TB, criminal record clearance and proof of CPR training. One out of two staff files contained proof of required training. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medication is not being administered as prescribed for resident 1 (R1). Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.