Routine inspection·August 12, 2025

On August 12, 2025, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Administrator (AD) and Licensee Arvin Bumanglag and Linh Nguyen arrived shortly after and was present to assist with the facility inspection on today's date. The facility is licensed for capacity six (6) residents of which two (2) can be non-ambulatory, four (4) ambulatory and one (1) bedridden residents. Facility has approved hospice waiver for six (6) residents. Currently, there are two (2) Hospice residents present during today’s visit. This is a single story with a attached garage facility. The facility has three resident bedrooms, one full bathroom and one half bathroom. At around 8:45AM, LPA Tirre conducted a tour of the physical plant accompanied by Caregiver, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 109.5 to 118.5 degrees F. A comfortable temperature of 74 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has a fire extinguisher which was mounted and fully charged. CONTINUED ON 809C A review of the Medication Records Administration (MAR) and Centrally stored medication destruction record was conducted for three residents and LPA observed the records are in compliance. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed the facility has supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. The last fire drill was conducted on June 28, 2025. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 8/3/2025 – 8/3/2026. A review of three residents (R1-R3) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Arvin Bumanglag # 7002119740 - Expiration 12/10/2026. Administrator certification confirmed on CCLD Administration Certification List. During visit Licensee expressed interest in increasing the capacity from 6 to 9 residents. LPA advised Licensee / administrator to submit the following for the capacity increase application. 1. Increase in Capacity Application 2. LIC 200 – Fire clearance 3. New floor plan (sketch) 4. Approved Conditional Use Permit (required above 6 residents) Licensee to submit documents to Regional Office No deficiencies during this inspection visit. An exit interview was conducted with Licensee’s Arvin Bumanaglag and Linh Nguyen, and a copy of the report was provided.