Routine inspection·September 17, 2025

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA was greeted and granted entry by Caregiver R S Kristian Umali after stating the reason for the visit followed by the live in House Manager (HM) Amelia Morales. The administrator's certificate for Theresa Kholoma is currently valid and expires on August 28, 2027. The following was observed during the inspection: This is a two story property located in a residential neighborhood. Facility operates within the conditions and limitations specified on the license. LPA observed six residents in care with two residents receiving hospice service. LPA observed two caregivers on duty and verified fingerprint clearance and association statuses. All common areas were inspected including the attached two car garage and the attic on the second floor which consisted of two private bedrooms for staff and one bathroom. On the first floor, LPA observed four resident bedrooms and two resident bathrooms. LPA observed the residents' bedrooms were appropriately furnished, beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space for each residents' personal belongings were observed. There were no bed rail orders for five out of six residents per review of the resident files. All bathrooms were unclean and unsanitary evidenced by the feces in the toilet bowl in the private bathroom of Resident #1 (R1) and Resident #2 (R2), all bathroom sinks had hard water stains, rust, and pink stains as well as the dirty floor evidenced by the debris and particles. LPA observed staff cleaning the facility approximately 11am. The cold water temperature in R1 and R2's bathroom was not cool enough measuring at 82 degrees Fahrenheit. LPA observed Staff #2 (S2) not following the infection control practices as they did not remove their glove and wash their hands after changing a resident's brief prior to opening the kitchen cabinet. The hot water temperature in the residents' bathrooms measured at 114.9 and 118.4 degrees Fahrenheit. 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. LPA toured the exterior portion of the facility. LPA observed the outdoor passageway is free of obstruction. The exit gates were operational and there were sufficient seating and shading. The fire extinguisher was mounted, charged, and serviced on August 22, 2025. The auditory devices and smoke/carbon monoxide detectors were tested and operational on both floors. LPA observed the emergency food/water and supplies in the garage and below the office desk. Emergency drills were conducted quarterly with the the last date on May 25, 2025. The Emergency Disaster Plan (LIC610E) was not reviewed annually. LPA observed the required 'See Something, Say Something' (PUB475) poster posted in the correct size. LPA interviewed residents/staff, reviewed six residents' files, and two personnel files in which discrepancies were found in the staff files. Medications were audited for two out of six residents. No discrepancies found. The following was discussed: to ensure facility is clean, sanitary, and in good repair at all times, completion of the LIC503s for S1 and S2, to adhere infection control practices, to review the the LIC610E annually and to complete page 9 of the plan, and to obtain bed rail orders for the five residents, (R1, R2, Residents #4-6). Based on the observations made during today's visit, deficiencies are being cited and Advisory Notes are being issued on the attached LIC9102s. An exit interview was conducted with House Manager Amelia Morales, and a copy of this report including the Confidential Names (LIC811s) and the appeal rights provided at exit.