Routine inspection·October 30, 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 Caregiver Joel Castillo and explained the reason for the visit. Administrator (Admin) Frank Mangisi arrived on premise to assist with the inspection. The administrator's certificate for Frank Mangisi is expired and is pending completion of course work for 2025. Admin completed 28 out of 40 hours for this year and indciated that all course work will be completed by November 30, 2025. The following was observed during the inspection: This is a single story residential home comprised of six private resident bedrooms and three shared and one private resident bathrooms. There is an additional bedroom occupied by two live-in staff. Facility operates within the conditions and limitations specified on the license. LPA observed six residents in care and two caregivers on duty during the visit. All common areas were inspected which includes the attached two car garage which also serves as a storage and laundry area. LPA inspected all bedrooms. The resident 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. All bathrooms were found be in compliance, clean, and operational. Slip resistant mats were provided. The hot water temperature in the resident bathrooms measured at 116.6, 107.6, 111.7, and 106.5 degrees Fahrenheit. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food in the kitchen. LPA tested and observed all four burners lighted unassisted. The toxins, disinfects, sharps, and medications were secured and inaccessible. LPA observed the interior/exterior kitchen appliances and pantry needed a deep cleaning as well as replacing one light fixture in the hallway. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The two exit gates on each side of the property was functional, and there were sufficient seating and shading in the patio area. The fireplace was appropriately screened. The two fire extinguishers were purchased on today's date per proof of receipt. The smoke/carbon monoxide detectors and all auditory devices tested operational except one smoke detector in the hallway. LPA observed emergency food/water in the garage. The first aid kit had all necessary elements. Facility is not conducting quarterly emergency drills. Admin stated that the drill will be conducted per shift next month. LPA reviewed two personnel files in which discrepancies were found. LPA confirmed per review of the Licensing Information System (LIS) Facility Personnel Report Summary and Guardian Background Check System that two out of the three staff were not fingerprint cleared, Staff #2 (S2) and Staff #3 (S3). Per file review, personnel records were incomplete and not maintained on file. LPA was unable to verify the initial 40 hour training records for S2 and S3, no health screening (which includes Tuberculosis (TB) test results) for S3 was maintained, and CPR/First Aid certificates for S2 to Staff #4 (S4) were missing. LPA reviewed six resident files and discrepancies were found as complete resident records were not maintained on file for all residents, reappraisals were not conducted for all residents, no medical assessments including TB tests were not completed for three out of six residents (Resident #2 (R2), Resident #4 (R4), and Resident #5 (R5). LPA found no medication errors in review of two out of six residents'. The following was addressed during the visit: to ensure complete resident/personnel records are maintained on file and readily available for review, obtain medical assessments/TB testing for R2, R4, and R5, to complete reappraisals and care plans for all residents, to provide proof of fingerprint clearance receipts tomorrow for S2 and S3, to obtain health screening and TB test result for S3, ensure both staff receives 40 hour training and documentation of training is maintained, to conduct quarterly emergency drills per shift effective November 2025, to deep clean the kitchen appliances and pantry, to repair one smoke detector and one light fixture, and to submit proof of liability insurance. Based on the observations made during today's visit, deficiencies are being cited and an immediate civil penalty is being assessed. Advisory Notes are also being issued. An exit interview was conducted with Administrator Frank Mangisi, and a copy of this report including the LIC858/859, and appeal rights were provided at exit.