Routine inspection·May 13, 2025

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Administrator (Admin) Heidi Baha and explained the reason for the visit. Administrator (Admin) Guibilondo holds a valid certificate expiring on March 1, 2027. The facility is a single story structure and is licensed to provide services for age range 60 and over for six non-ambulatory. A waiver was granted to provide hospice services to three residents at one time. During today's visit, two residents were under hospice care, two caregivers were on duty providing care to five residents who were observed relaxing in the living room and their respective bedrooms. LPA toured the physical plant with Admin. Facility is clean, operational, and in good repair with the exception of one resident bedroom. The hardwood floor and closet door are being repaired due to the water damage. The Department was not notified of the alterations being made prior to the renovations. LPA observed five resident bedrooms and bathrooms. There is one additional staff bedroom shared by two staff. Resident bedrooms had all required furnishings. Bathrooms were in compliance, clean, and operational. The hot water temperature measured at 107.2, 105.8, 105.9, 105.2, and 105.8 degrees Fahrenheit in the resident bathrooms. All common areas were inspected including the attached two car garage. LPA reviewed the Emergency Disaster Plan (LIC610E) and observed sufficient water in the pantry walk in closet. There were no emergency food observed. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available in the kitchen and garage. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The exit gates were in good repair. LPA observed sufficient seating and shading. The fire extinguishers in the kitchen and garage were invalid expiring on July 19, 2023. The auditory devices and smoke/carbon monoxide detectors were tested and operational. Emergency evacuation drills are not conducted quarterly. The facility land line number, (949) 454-8349, was tested and remains available. The Complaint Poster, 'See Something, Say Something,' (PUB 475) was available in an incorrect size and posted on the bulletin board. LPA conducted a review of all residents and two staff files. Discrepancies observed in the resident files as the medical assessments (LIC602s) were not updated annually in three out of five residents. Discrepancies observed in the staff files as the staff did not complete 40 hours of annual training, the health screening was not completed for one staff and Tuberculosis (TB) tests were incomplete in two out of two staff files reviewed. The medications were audited in two out of five residents. No discrepancies noted. No interviews were conducted due to time constraints. The following items were addressed with the Admin: to conduct quarterly emergency drills, to notify the Department prior to any alterations, to ensure 40 hour staff training is completed annually, to ensure fire extinguishers are current, to complete Health Screening (LIC503) for Staff #2 (S2) and TB tests for both staff, and to obtain medical assessments (LIC602s) for three out of five residents. Based on the observations made during today's visit, deficiencies are being cited. See attached LIC809Ds. Civil penalties for repeat violations are being assessed. See LIC421FCs. Advisory Notes (LIC9102s) are being issued. An exit interview was conducted with Administrator Heidi Baha, and a copy of this report including the LIC809C, LIC809Ds, LIC9102s, LIC421FCs, LIC811s, and the appeal rights were provided at the end of the visit.