Routine inspection·December 12, 2025

On December 12, 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 met with Administrator (ADMIN) Maria Parungao and explained the purpose of the visit. The facility is licensed to operate for five (5) non-ambulatory of which one (1) may be bedridden, and have a hospice waiver for five (5) residents. The facility is a single-story building 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, attached 2-car garage, and an outside covered patio area. LPA Kim toured indoor and outdoor of the physical plant with Caregiver (CG) Pelagia Estevez. There are no obstructions or bodies of water on the premises. 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. All bedrooms 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 between 111.5 degrees F and 112.8 degrees F . A comfortable temperature of 74 degrees F was maintained in the facility. LPA Kim observed the facility to be sanitary and 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 The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, water, and supplies are stored in the garage. The facility has one (1) fire extinguisher that is charged and was serviced on November 25, 2025. All smoke/carbon monoxide detectors were operable. 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). The facility conducted a Fire/Safety Drill quarterly. A working telephone (714-9689-795) remains available. The facility did not have a device with videoconferencing technology dedicated for resident use. First Aid Kit contained all the necessary elements. Evidence of Liability Insurance was effective from September 19, 2025, to September 19, 2026. LPA conducted an audit of resident files (R1-R5), staff files (S1-S5) and medication and medication administration record that were all in order and completed. LPA Kim conducted 1 resident interview and 2 staff interviews. A technical violation was issued at the time of the visit. Facility did not have a device with videoconferencing technology dedicated for resident use An exit interview was conducted, and a copy of this report and LIC9102 were provided to Administrator Maria Parungao.