Routine inspection·May 14, 2025

On May 14, 2025, at 8:00 AM, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Caregiver (CG) Virgilio Herrera. Administrator (AD) Arlene Fajardo arrived at the facility around 8:15 AM and LPA Kim explained the purpose of the visit. The facility is licensed to operate for six (6) nonambulatory residents, and has a hospice waiver for four (4) residents. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, one (1) staff bedroom, two (2) bathrooms, living area, dining area, kitchen, shaded table with chairs in the backyard, and an attached two car garage. LPA Kim toured inside and outside of the physical plant with ADMIN Fajardo. There were no bodies of water or obstructions in the facility. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each resident's personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Resident’s rooms were inspected: Resident Room 1, Resident Room 2, Resident Room 3, and Resident Room 4. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 114.1 degrees F to 114.3 degrees F. A comfortable temperature of 71 degrees F was maintained in the facility. LPA Kim observed the facility to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. Evaluation Report Continues on LIC 809-C During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and residents. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). Emergency food, emergency water, and emergency supplies are stored in the garage. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food both were available and maintained properly. The facility has one (1) fire extinguisher that is charged and mounted in the kitchen, and was last inspected on May 9, 2025. All mandated inspection control posters were posted. The smoke detectors and carbon monoxide detectors were operable. A working telephone (657-301-2481) and video teleconferencing tablet dedicated to the residents both remain available. Last emergency drill was conducted on March 20, 2025. First aid kit is maintained and contains all the necessary elements. Evidence of Liability is effective July 1, 2024, and expires July 1, 2025. LPA Kim conducted an audit of resident files (R1-R6), staff files (S1-S5), and medication and medication administration record. Appraisals for R1, R2, and R3 were dated from May 14, 2023. S1 did not have a valid TB test in their record. LPA Kim conducted two (2) resident interviews. Deficiencies were cited during this visit per Title 22 Division 6 Chapter 8. LPA observed R1, R2, and R3 had their reappraisals last done on May 14, 2023, and S1 did not have valid TB test in their record. An exit interview was conducted, and a copy of this report and appeal rights were provided to Administrator Arlene Fajardo.