Routine inspection·June 19, 2024

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1 Year Inspection using the Care Inspection Tool. LPA Cho was greeted and granted entry by Administrator (Admin) Benigno Bulanadi. Licensee/Administrator Herminia Zuehl arrived shortly. The facility is a single story structure located in a residential neighborhood. Facility is licensed to operate for six (6) non-ambulatory in which one (1) may be bedridden and maintains a hospice waiver for six (6). There is one (1) bedridden resident and three (3) residents under hospice care on today's date. LPA toured the interior and exterior portions of the facility. There are a total of five resident bedrooms and one resident bathroom. There is one staff bedroom and bathroom. LPA observed the facility to be clean, sanitary, and operational. The resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke/carbon monoxide detectors and auditory exit alarms were tested and operational. LPA observed resident bathroom to be in good repair, provided with handrails, and a non-skid floor mat. The hot water temperature measured at 109.4 degrees Fahrenheit in the resident bathroom and 112.4 in the staff/guest bathroom. Facility met the two day perishable and seven day non-perishable food supplies. LPA observed medications, toxins, and sharps were inaccessible to the residents. The fire extinguisher was serviced on April 14, 2024. LPA observed clutter in the garage which is a safety hazard and administrators were advised to clear the clutter. For the exterior portion, facility had sufficient seating and shading. The exit doors were self-closing and self-latching. LPA observed the emergency disaster supplies including food/water. LPA observed the required "See Something, Say Something' (PUB475) poster in the required size. Administrator's Certificate for Beningno Bulanadi expires on July 17, 2025. LPA conducted an audit of six residents' files and two staff files. A discrepancy was observed with one resident file as no proof of TB testing was provided for Resident #1 (R1). No discrepancies for the staff files. Resident interviews were conducted however LPA could not meet with the caregivers as one staff was preparing dinner while the other was assisting residents. Medications were audited. No discrepancies noted. LPA consulted the following: to clear the clutter in the garage in order to adhere to the regulations by the State Fire Marshal, to obtain a Tuberculosis test result for R1, and to pay the annual licensing fee that was due on June 10, 2024. Based on the observations made during today's visit, deficiencies are being cited as per Title 22 Division 6 Chapter 8 of the California Code of Regulations. See the attached LIC9099D. An exit interview was conducted with Administrators Herminia Zuehl and Beningo Bulanadi, and a copy of this report including the LIC809C, LIC809D, LIC811s, and the appeal rights were provided during this visit.