Routine inspection·September 23, 2025

On 09/23/2025 Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff Alexandra Manwill and explained the purpose of the visit. Direct care staff called the facility house manager Juan Rameriez to inform him that CCLD was present in the facility. House Manager Rameriez was not able to attend the visit and directed care staff to assist LPA Lee with the inspection. The Administrator certificate # is 7011766740 and will expire on 06/08/2026. The current census is 6 with 1 facility staff. This facility is a single story building licensed to serve six (6) non-ambulatory residents and approved for 6 hospices wavier. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 125.4 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. CONTINUED LIC 809-C The fire extinguisher is located in the dining room and was last serviced on 03/28/2025. LPA Lee observed the facility has a has a public telephone in the kitchen. LPA Lee observed the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) was not the correct size of The 20" X 26". The facility thermostat was observed at 74 degrees Fahrenheit. LPA Lee observed toxins located in kitchen cabinets and kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked in the kitchen cabinet and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 3 out of 6 resident medications on hand and the medication administration record (MAR) and it was complete. The first aid kit was checked and contained the required components. LPA Lee requested resident and staff files for review. LPA Lee reviewed 6 out of 6 resident files and 1 out of 6 resident files were incomplete. Resident 1 (R1) were missing TB test. LPA Lee reviewed 2 staff files, and it was complete. LPA Lee reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated with the facility. The following documents will be emailed to LPA by 10/03/2025 end of day 5:00 PM: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with direct care staff Manwill and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.