Routine inspection·April 28, 2025

On 4/28/25 at 1 PM, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry into the facility by Adminstrator (AD) Dennis DeLa Cruz after explaining the purpose for today's visit. LPA observed that Administrator Dennis DeLa Cruz has a valid Administrator certificate which expires January 18, 2026. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents on the first floor, and has a hospice waiver for four. The facility is a two story home with three shared resident bedrooms on the first floor, two shared resident bathrooms on the first floor, a living room, a dining room, a kitchen, two staff bedrooms upstairs, one staff bathroom upstairs, and an attached two car garage. LPA, accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed five residents in care, one of which is on hospice, and three staff present. LPA observed residents relaxing in their respective bedrooms and in common areas. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. LPA inspected the three shared resident bedrooms and they were observed to be free of hazards. LPA observed resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds to have clean linens and blankets. LPA observed additional linens to be stored in a hallway closet. LPA inspected the two residents bathrooms and they were observed to be clear of hazards. Resident bathrooms were equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 113.5 and 114 degrees Fahrenheit. LPA observed the second story of the facility is for staff use only and is off limits to residents in care. CONTINUED ON 809-C LPA observed the kitchen has a two day perishable and a seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed the four burner gas stove lights unassisted. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. LPA observed a fire extinguisher to be mounted on the wall in the kitchen. The fire extinguisher was observed to be charged and up to date on service. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility does not keep a log of the emergency disaster drills it conducts. LPA observed the centrally stored medication to be kept in a locked cabinet in the kitchen. LPA observed a First Aid Kit to be stored in a locked kitchen cabinet and it had all the required components. LPA observed a fireplace in the living room and it was observed to be adequately fenced and not in operation at time of visit. LPA observed the door leading to the attached two car garage to be kept locked and inaccessible to residents in care. LPA observed the garage to be used for storage and laundry. LPA observed chemicals and toxins to be stored in the garage. LPA observed the facility has a three day emergency food and water supply stored in the garage. LPA, accompanied by the AD, conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be free of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. LPA observed the perimeter gates on the north side and west side of the facility to be self latching and can be opened in an evacuation. LPA observed a pool in the backyard. LPA observed the pool to be adequately fenced and kept locked for resident safety. LPA reviewed all five resident files. LPA observed the facility did not have a Pre-Admission Agreement on file for Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5. LPA observed the facility did not have a Reappraisal on file for Resident #3 and Resident #4. LPA observed the Reappraisals for Resident #1, Resident #2, and Resident #5 to be outdated. LPA reviewed residents' medication and medication records. LPA reviewed five staff files. All staff are background cleared and associated to the facility. Based on the observations made during today's visit, deficiencies are being cited on the attached 809-Ds. An exit interview was conducted with Administrator Dennis DeLa Cruz. A copy of the report and Appeal Rights were provided.