Routine inspection·April 24, 2026

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 Blanca Gonzalez after introducing and stating the reason for the visit. LPA also met with Administrator Mary Jean Alvarado and Administrator's Assistant Jilmark Realis. Admin Alvarado has a valid certificate expiring on 6/8/26. The following was observed during the inspection: This is a single story property comprised of four resident bedrooms and four resident bathrooms. There is an additional private bedroom designated for two live-in staff. Facility is operating within the conditions and limitations specified on the license. LPA observed five residents in care, one of which is receiving hospice service. LPA toured the interior portion of the facility. The facility is clean and in good repair. All common areas were inspected including the attached two car garage. LPA inspected all resident 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 available. The hot water temperature in the resident bathrooms did not meet the regulation measuring at 117.8, 118.4, 121.1, and 120.9 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. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The exit gate is operational, and there were sufficient seating and shading in the patio area. There are no bodies of water on premise. The fireplace in a resident's bedroom was screened. The fire extinguisher was mounted, charged, and serviced on May 9, 2024 which did not meet the regulation. The auditory devices and smoke/carbon monoxide detectors were tested and operational. However, the smoke detector that was removed in one resident's room had to be reinstalled and Admin will ensure that it is operational. Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the correct size. LPA reviewed two personnel files in which no discrepancies were found. Staff training is completed for one of two staff. Staff #2 (S2) has a start date of April 15, 2026, and Admin stated S2 will receive training immediately. LPA reviewed five resident files in which discrepancies were found as no Medical Assessments (LIC602s) which include Tuberculosis (TB) tests were not completed for two of five residents. Medications were audited for two of five residents. However, medications administered were not documented on the Medication Administration Record (MAR) for both residents timely missing 3-13 days. Present staff is background cleared and associated to the facility. Disaster drills are conducted quarterly as last known drill per log was conducted January 20, 2026. LPA consulted on the following: to ensure that the resident/personnel files are maintained and organized to prevent future delays in visit, to ensure medical assessments are completed and TB tests are obtained timely, to ensure the hot water temperature is within a comfortable range of 105-120 degrees Fahrenheit, to ensure fire extinguisher is serviced or purchased annually, to ensure resident does not remove the smoke detector and to ensure it's operational, and to ensure staff completes the Medication Administration Record timely. Based on the observations made during today's visit, deficiencies are being cited, and Technical Violations are also being issued. An exit interview was conducted with Administrator Mary Jean Alvarado and Administrator's Assistant Jilmark Realis, and a copy of this report including the appeal rights were provided at exit.