Routine inspection·January 22, 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 Maria Cosio Bazan. Administrator Johan Mathews arrived after being notified of the visit. The facility is a single story structure located in a residential neighborhood. Facility is licensed to operate for six non-ambulatory and maintains a hospice waiver for six residents. There are six residents in care with one receiving hospice care and two caregivers on duty during today's visit. LPA observed the facility to be clean, sanitary, and operational. There are five resident bedrooms and five resident bathrooms. There is one additional bedroom occupied by two live-in staff. All common areas were inspected including the attached two car garage and laundry room. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for each residents' personal belongings were observed. Bathrooms were found to be in compliance, clean, and operational. The water temperature measured at 111.7, 106.8, 106.5, 105.0, and 105.0 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 available. The fireplace was screened. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The exit gate was self-closing and self-latching. LPA observed sufficient seating and shading. Facility maintains two fire extinguishers which were observed mounted, charged, and serviced on July 1, 2024. The auditory devices and smoke/carbon monoxide detectors were tested and operational. LPA observed the emergency disaster supplies including food/water in the laundry room and garage. Emergency evacuation drills are being conducted quarterly. The first aid kit contains all necessary elements. The first aid manual is available. The facility land line number, 949-446-6085, was tested and remains available. The liability insurance is also current. LPA observed the required 'See Something, Say Something' poster (PUB475) in the correct size. The Administrator's Certificate for Johan Mathews expires on June 13, 2026 and April 11, 2026 for Rosa Reyes. LPA conducted an audit of six residents' files and two personnel files. No discrepancies noted. Medications were audited for three residents. No discrepancies noted. Staff and resident interviews were conducted. The following items were noted and discussed with Admin Mathews: to amend the Emergency Disaster Plan (LIC610E) and to ensure timely payment of the annual licensing fee due February 22, 2025. Based on the observations made during today's visit, no deficiencies are being cited. An Advisory Note (LIC9102) is being issued. An exit interview was conducted with Administrator Johan Mathews, and a copy of this report and the LIC9102 were provided at the end of the visit.